Basic Information
| Provider Information | |||||||||
| NPI: | 1740309624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLCOMB | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | OMAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30055 NORTHWESTERN HWY STE L-30 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488654238 | ||||||||
| FaxNumber: | 2488654237 | ||||||||
| Practice Location | |||||||||
| Address1: | 2070 BIDDLE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342259100 | ||||||||
| FaxNumber: | 7342259100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301080364 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0H28427 | 01 | MI | BLUE CROSS | OTHER | 1699102244 | 01 | GROUP NPI HENRY FORD WYANDOTTE | OTHER |