Basic Information
Provider Information | |||||||||
NPI: | 1356393078 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLIS | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2020 EXETER RD | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 381383945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9017473630 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 27 MEDICAL CENTER DR | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383013949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7314241001 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 06/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 24538 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 3076068 | 05 | TN |   | MEDICAID | 8165 | 01 | TN | TLC PROVIDER NUMBER | OTHER | 4472668 | 01 | TN | AETNA PROVIDER NUMBER | OTHER | 100008392 | 01 | TN | RAILROAD MEDICARE | OTHER | 170088 | 01 | TN | BCBS PROVIDER NUMBER | OTHER | 8262001 | 01 | TN | CIGNA HEALTHCARE | OTHER |