Healthcare Provider Details

I. General information

NPI: 1831492180
Provider Name (Legal Business Name): HOLLY D. CASEY, MD, A PROFESSIONAL MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 FERN AVENUE
SHREVEPORT LA
71105
US

IV. Provider business mailing address

8600 FERN AVENUE
SHREVEPORT LA
71105
US

V. Phone/Fax

Practice location:
  • Phone: 318-795-0801
  • Fax: 318-795-9492
Mailing address:
  • Phone: 318-795-0801
  • Fax: 318-795-9492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberL14095R
License Number StateLA

VIII. Authorized Official

Name: DR. HOLLY D. CASEY
Title or Position: MEMBER
Credential: MD
Phone: 318-795-0801