Basic Information
| Provider Information | |||||||||
| NPI: | 1801187315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ANDERS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 N 8TH AVE E | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187231112 | ||||||||
| FaxNumber: | 2185299120 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 N 8TH AVE E | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187231112 | ||||||||
| FaxNumber: | 2185299120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2011 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 55316 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1801187315 | 01 | MN | BCBS | OTHER | 0001-0100288 | 01 | MEDICA | OTHER | 1801187315 | 05 | MN | MEDICAID | P01099783 | 01 | RR MEDICARE | OTHER |