Basic Information
| Provider Information | |||||||||
| NPI: | 1053407023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRED JAMIE W HOLLAND II MD PC | ||||||||
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| OtherOrganizationName: | CARDIOTHORACIC AND VASCULAR SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 PEACH ST | ||||||||
| Address2: | SUITE LL1 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148605000 | ||||||||
| FaxNumber: | 8148605050 | ||||||||
| Practice Location | |||||||||
| Address1: | 2314 SASSAFRAS ST | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165022722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144569197 | ||||||||
| FaxNumber: | 8144552765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOLLAND | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8144569197 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 1014522940002 | 05 | PA | MEDICAID |