1053363887 NPI number — TALLULAH HOLMSTROM MD

Table of content: TALLULAH HOLMSTROM MD (NPI 1053363887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053363887 NPI number — TALLULAH HOLMSTROM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLMSTROM
Provider First Name:
TALLULAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053363887
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1259
Provider Second Line Business Mailing Address:
SENTINEL HEALTH PARTNERS PA
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29021-1259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-713-8350
Provider Business Mailing Address Fax Number:
803-713-8433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 DEWITT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUGOFF
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29078-9069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-438-7566
Provider Business Practice Location Address Fax Number:
803-438-4371
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  16660 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 166607 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110143766 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 64417 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".




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