Provider Demographics
NPI:1902899792
Name:ABDERHOLDEN, GUY R (MD)
Entity Type:Individual
Prefix:MR
First Name:GUY
Middle Name:R
Last Name:ABDERHOLDEN
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 1:543 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-3107
Mailing Address - Country:US
Mailing Address - Phone:847-395-3322
Mailing Address - Fax:847-395-0921
Practice Address - Street 1:543 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-3107
Practice Address - Country:US
Practice Address - Phone:847-395-3322
Practice Address - Fax:847-395-0921
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33453020207Q00000X
IL036-084853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360848531Medicaid
F34603Medicare UPIN
IL0360848531Medicaid