Provider Demographics
NPI:1740471077
Name:HOLLES-SOBOTA, STACI M (DO)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:M
Last Name:HOLLES-SOBOTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PICCARD DRIVE
Mailing Address - Street 2:SUITE 202 EMERGENCY MEDICINE ASSOCIATES
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4303
Mailing Address - Country:US
Mailing Address - Phone:301-921-7900
Mailing Address - Fax:301-921-7915
Practice Address - Street 1:8384 CHARLOTTE HWY
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-6532
Practice Address - Country:US
Practice Address - Phone:703-689-9037
Practice Address - Fax:703-689-9109
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37739207P00000X, 207Q00000X
VA0102202037207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC377391Medicaid