Basic Information
| Provider Information | |||||||||
| NPI: | 1457425480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | ANDRE' | ||||||||
| MiddleName: | RESHAUN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 915 EAGLES LANDING PKWY | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302815011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709966699 | ||||||||
| FaxNumber: | 7709974790 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 EAGLES LANDING PKWY | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302815011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709966699 | ||||||||
| FaxNumber: | 7709974790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 67644 | GA | N | Other Service Providers | Specialist | 207RC0200X | 67644 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 67644 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 003123920A | 05 | GA | MEDICAID |