Provider Demographics
NPI:1295833408
Name:HOLM-ANDERSEN, INGOLF (MD)
Entity Type:Individual
Prefix:MR
First Name:INGOLF
Middle Name:
Last Name:HOLM-ANDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:I
Other - Middle Name:
Other - Last Name:HOLM-ANDERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10 MEDICAL PLAZA
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542
Mailing Address - Country:US
Mailing Address - Phone:516-759-0448
Mailing Address - Fax:516-759-0453
Practice Address - Street 1:10 MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542
Practice Address - Country:US
Practice Address - Phone:516-759-0448
Practice Address - Fax:516-759-0453
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B17814Medicare UPIN
NY676231Medicare PIN