Provider Demographics
NPI:1053363887
Name:HOLMSTROM, TALLULAH (MD)
Entity type:Individual
Prefix:
First Name:TALLULAH
Middle Name:
Last Name:HOLMSTROM
Suffix:
Gender:F
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:PO BOX 1259
Mailing Address - Street 2:SENTINEL HEALTH PARTNERS PA
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29021-1259
Mailing Address - Country:US
Mailing Address - Phone:803-713-8350
Mailing Address - Fax:803-713-8433
Practice Address - Street 1:710 DEWITT DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9069
Practice Address - Country:US
Practice Address - Phone:803-438-7566
Practice Address - Fax:803-438-4371
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC166607Medicaid
SC110143766OtherRAILROAD MEDICARE PIN
64417OtherMEDCOST
SC166607Medicaid
SCG071845360Medicare PIN