Provider Demographics
NPI:1295718781
Name:HOLT, RONALD (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:HOLT
Suffix:
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 1:2961 TWO PATHS DR
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4512
Mailing Address - Country:US
Mailing Address - Phone:708-422-4221
Mailing Address - Fax:708-422-4415
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2746
Practice Address - Country:US
Practice Address - Phone:708-422-4221
Practice Address - Fax:708-422-4415
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066295207PE0004X, 261QM1300X
IL036.066295207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036033295OtherBLUE CROSS BLUE SHIELD
IL036066295Medicaid
ILC42941Medicare UPIN
IL036033295OtherBLUE CROSS BLUE SHIELD