Basic Information
Provider Information | |||||||||
NPI: | 1437117561 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLABAUGH | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | STERLING | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1325 WOLF PARK DR | ||||||||
Address2: | SUITE 103 | ||||||||
City: | GERMANTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 381381742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9012523411 | ||||||||
FaxNumber: | 9013846422 | ||||||||
Practice Location | |||||||||
Address1: | 1325 WOLF PARK DR | ||||||||
Address2: | SUITE 102 | ||||||||
City: | GERMANTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 381381742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9012523400 | ||||||||
FaxNumber: | 9016820047 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2006 | ||||||||
LastUpdateDate: | 11/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 30313 | TN | Y |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | 15804 | MS | N |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 0210025600 | 01 |   | QUAL CHOICE | OTHER | 133261 | 01 |   | HEALTH LINK | OTHER | 3823224 | 05 | TN |   | MEDICAID | 13137372 | 01 |   | PHCS | OTHER | 3095141 | 01 | TN | BLUE CROSS | OTHER | 4574106 | 01 |   | CIGNA | OTHER | 4025294 | 01 |   | AETNA | OTHER | 1201660 | 01 |   | FIRST HEALTH | OTHER | 97879 | 01 |   | BLUE CROSS AR | OTHER |