Basic Information
| Provider Information | |||||||||
| NPI: | 1073547782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLEY | ||||||||
| FirstName: | EVERETT | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035314262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | L6065 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 158367610 | 05 | TX | MEDICAID | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 8DU752 | 01 | TX | BCBS | OTHER | P01304462 | 01 | TX | RAIL ROAD | OTHER | 158367611 | 05 | TX | MEDICAID | 751976930005 | 01 | TX | TRICARE | OTHER | P00662854 | 01 | TX | RAIL ROAD | OTHER | 158367613 | 05 | TX | MEDICAID | P00792073 | 01 | TX | RAIL ROAD | OTHER | 158367612 | 05 | TX | MEDICAID | 75-2616977-01 | 01 | TX | TRICARE | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 75-0818167-048 | 01 | TX | TRICARE | OTHER | TIN PLUS 015 | 01 | TX | TRICARE | OTHER | 158367614 | 05 | TX | MEDICAID | 750818167015 | 01 | TX | TRICARE | OTHER | 750818167044 | 01 | TX | TRICARE | OTHER | 75-0818167022 | 01 | TX | TRICARE | OTHER | 8X8161 | 01 | TX | BCBS | OTHER |