Provider Demographics
NPI:1700871266
Name:HOLT, MICHAEL R (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:HOLT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF RADIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3700
Mailing Address - Fax:414-805-3777
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF RADIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3700
Practice Address - Fax:414-805-3777
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN010423092085R0202X, 2085B0100X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0204X, 2085U0001X, 2085R0203X
WI304112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100364900Medicaid
IN728230YMedicare PIN
IN100364900Medicaid