Provider Demographics
NPI:1679892707
Name:HOLST, ASHLEE KAYE (DO)
Entity Type:Individual
Prefix:
First Name:ASHLEE
Middle Name:KAYE
Last Name:HOLST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ASHLEE
Other - Middle Name:KAYE
Other - Last Name:BALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 JOHN DEERE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6812
Mailing Address - Country:US
Mailing Address - Phone:309-779-4200
Mailing Address - Fax:309-779-4305
Practice Address - Street 1:600 JOHN DEERE RD STE 200
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6812
Practice Address - Country:US
Practice Address - Phone:309-779-4200
Practice Address - Fax:309-779-4305
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4410207R00000X
IL036141459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036141459OtherBLUE SHIELD OF ILLINOIS
MN1679892707Medicaid
IA1679892707Medicaid
IL036141459Medicaid
ILF400327503Medicare PIN
IL036141459OtherBLUE SHIELD OF ILLINOIS