Basic Information
| Provider Information | |||||||||
| NPI: | 1790731545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLBROOK | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
| FaxNumber: | 3148101399 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 E BOONESLICK RD | ||||||||
| Address2: | |||||||||
| City: | WARRENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633832127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364560188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 01/15/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 103133 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PP0204X | 103133 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1790731545 | 05 | MO | MEDICAID |