Provider Demographics
NPI:1790731545
Name:HOLBROOK, ANGELA M (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:605 E BOONESLICK RD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-2127
Practice Address - Country:US
Practice Address - Phone:636-456-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103133207P00000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790731545Medicaid
IL$$$$$$$$$Medicaid
IL$$$$$$$$$Medicaid
MO134050091Medicare ID - Type UnspecifiedSJH-MO
MO1790731545Medicaid
MO156580011Medicare PIN