Provider Demographics
NPI:1760604623
Name:IMHOLTE, PHILIP BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:BRUCE
Last Name:IMHOLTE
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 1:1601 GOLF COURSE ROAD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-326-5000
Mailing Address - Fax:218-999-1380
Practice Address - Street 1:1601 GOLF COURSE ROAD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-5000
Practice Address - Fax:218-999-1380
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1760604623OtherMEDICA
MN17P85IMOtherBCBS
MN244940000Medicaid
P00438363OtherRR MEDICARE PTAN
MN17P85IMOtherBCBS