Provider Demographics
NPI:1982659561
Name:HOLLOWAY, NATHANIEL OVERTON III (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:OVERTON
Last Name:HOLLOWAY
Suffix:III
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 1:3400 N LAKE SHORE DR
Mailing Address - Street 2:UNIT 9-B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2827
Mailing Address - Country:US
Mailing Address - Phone:773-947-7850
Mailing Address - Fax:773-947-7852
Practice Address - Street 1:7531 S STONY ISLAND AVE
Practice Address - Street 2:BASEMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3954
Practice Address - Country:US
Practice Address - Phone:773-947-7850
Practice Address - Fax:773-947-7852
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360735422085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073542Medicaid
ILF19584Medicare UPIN
ILIL1885001Medicare PIN