Basic Information
| Provider Information | |||||||||
| NPI: | 1700152071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLTHOUSER | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 780982 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026298000 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2012 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | 49227 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2013832260 | 05 | IN | MEDICAID | 000001031584 | 01 | KY | ANTHEM - WS | OTHER | 7100263230 | 05 | KY | MEDICAID | 218353 | 01 | KY | SIHO - WS | OTHER | 50115089 | 01 | KY | PASSPORT - WS | OTHER |