Basic Information
| Provider Information | |||||||||
| NPI: | 1134253735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLAND | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270592 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800275009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059475557 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 N 30TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820725140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077422141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 04/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | TL784 | WY | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 314995 | 01 | WY | BCBS KID CARE | OTHER | 314995 | 01 | WY | BCBS | OTHER |