Provider Demographics
NPI:1578550703
Name:HOLSOMBACK, HENRY MERCER JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:MERCER
Last Name:HOLSOMBACK
Suffix:JR
Gender:M
Credentials:CRNA
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Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SULLIVANS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29482-0040
Mailing Address - Country:US
Mailing Address - Phone:843-883-5830
Mailing Address - Fax:843-883-5829
Practice Address - Street 1:302 UNIVERSITY PKWY
Practice Address - Street 2:AIKEN REGIONAL MEDICAL CENTER
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6302
Practice Address - Country:US
Practice Address - Phone:803-641-5489
Practice Address - Fax:803-641-5148
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2007-12-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC26114367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0053Medicaid
Q33229Medicare UPIN