Provider Demographics
NPI:1861466393
Name:HOLMES, ROBERT L (DO, PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:HOLMES
Suffix:
Gender:M
Credentials:DO, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W JACKSON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1474
Mailing Address - Country:US
Mailing Address - Phone:618-453-7777
Mailing Address - Fax:618-453-1102
Practice Address - Street 1:305 W JACKSON ST
Practice Address - Street 2:STE 200
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-453-7777
Practice Address - Fax:618-453-1102
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-081188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081188Medicaid
ILL62842Medicare ID - Type Unspecified
IL036081188Medicaid