Basic Information
| Provider Information | |||||||||
| NPI: | 1942383914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLLOMAN | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WESTPORT PLZ | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145484772 | ||||||||
| FaxNumber: | 3145484748 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 N NEW BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149965180 | ||||||||
| FaxNumber: | 3148212180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 03/18/2009 | ||||||||
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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 | 2085R0202X | R6596 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036061640 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 135370 | 01 | H LINK | OTHER | A12402 | 01 | GATE WAY | OTHER | 002013128 | 01 | CARE | OTHER | 1600226 | 01 | PH PLAN | OTHER | 6167 | 01 | MCARE USA | OTHER | 2781 | 01 | GHP | OTHER | 27600 | 01 | BLUE CHOICE | OTHER | 300066998 | 01 | RR CARE | OTHER | 017012444 | 01 | MO CARE | OTHER | 04802710571 | 01 | IL CAID | OTHER | 201047818 | 01 | MO CAID | OTHER | 201047818 | 01 | MC MCAID | OTHER | 431725842MID | 01 | MERCY | OTHER | 002013128 | 01 | MO CARE | OTHER | 017012444 | 01 | CARE | OTHER | 398023 | 01 | HLT PART | OTHER | 0090000352 | 01 | IL BLUE | OTHER | 1390 | 01 | MO BLUE | OTHER |