Basic Information
| Provider Information | |||||||||
| NPI: | 1396737516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLING | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232832 | ||||||||
| FaxNumber: | 7722235646 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SE HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722235618 | ||||||||
| FaxNumber: | 7722885834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | ME0054425 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | ME0054425 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 18604 | 01 | FL | FL BLUE | OTHER | 013390900 | 05 | FL | MEDICAID |