Provider Demographics
NPI:1821026519
Name:HOLT, PAIGE C (MD)
Entity Type:Individual
Prefix:DR
First Name:PAIGE
Middle Name:C
Last Name:HOLT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:B
Other - Last Name:CORNETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2502 E EMPIRE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3738
Mailing Address - Country:US
Mailing Address - Phone:309-664-4444
Mailing Address - Fax:309-664-5006
Practice Address - Street 1:2502 E EMPIRE ST
Practice Address - Street 2:SUITE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3738
Practice Address - Country:US
Practice Address - Phone:309-664-4444
Practice Address - Fax:309-664-5006
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116185208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116185Medicaid
ILI55392Medicare UPIN
IL036116185Medicaid
ILP00604462Medicare PIN