1174562599 NPI number — KEITH R HOLAN MD

Table of content: KEITH R HOLAN MD (NPI 1174562599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174562599 NPI number — KEITH R HOLAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLAN
Provider First Name:
KEITH
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174562599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 609
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUYAHOGA FALLS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44222-0609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-923-6606
Provider Business Mailing Address Fax Number:
330-923-8090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3033 STATE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUYAHOGA FALLS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44223-3614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-945-4739
Provider Business Practice Location Address Fax Number:
330-945-7381
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  35043324H , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0419210 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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