Provider Demographics
NPI:1609054766
Name:JUDY HOLTMAN
Entity Type:Organization
Organization Name:JUDY HOLTMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOLTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-583-6647
Mailing Address - Street 1:DEPT 8093
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0001
Mailing Address - Country:US
Mailing Address - Phone:866-286-9915
Mailing Address - Fax:
Practice Address - Street 1:444 S 1ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1416
Practice Address - Country:US
Practice Address - Phone:502-583-6647
Practice Address - Fax:502-585-4824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18578261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC72385Medicare UPIN
KY1567601Medicare PIN