Provider Demographics
NPI:1558366088
Name:HOLDEN, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:HOLDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 N. STATE HWY
Mailing Address - Street 2:
Mailing Address - City:NAUVOO
Mailing Address - State:IL
Mailing Address - Zip Code:62354-2472
Mailing Address - Country:US
Mailing Address - Phone:208-866-7169
Mailing Address - Fax:
Practice Address - Street 1:BROARDWAY AT 11TH STREET
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62350-7005
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6837207Q00000X
IL036118552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010001024OtherREGENCE BLUE SHIELD OF ID
ID003729600Medicaid
ID72942OtherBLUE CROSS OF ID
K38330Medicare PIN
ID000010001024OtherREGENCE BLUE SHIELD OF ID
F13756Medicare UPIN