Basic Information
| Provider Information | |||||||||
| NPI: | 1982681359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLADY | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893620153 | ||||||||
| FaxNumber: | 9893624683 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893620153 | ||||||||
| FaxNumber: | 9893624683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 4301059416 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 4592732 | 05 | MI | MEDICAID |