Healthcare Provider Details

I. General information

NPI: 1538154018
Provider Name (Legal Business Name): BYRON M HOLM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 MILLER DR STE 205
PLYMOUTH IN
46563-8093
US

IV. Provider business mailing address

2855 MILLER DR STE 205
PLYMOUTH IN
46563-8093
US

V. Phone/Fax

Practice location:
  • Phone: 574-936-7777
  • Fax: 888-247-3121
Mailing address:
  • Phone: 574-286-0200
  • Fax: 888-247-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01024911A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: