Basic Information
| Provider Information | |||||||||
| NPI: | 1598737728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLEY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 990 | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404230990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592395870 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 216 W WALNUT ST STE A | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404221832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592395870 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 39268 | SC | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 041833 | GA | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 55882 | KY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | GA1807 | 05 | SC | MEDICAID | 000707836O | 05 | GA | MEDICAID |