Healthcare Provider Details

I. General information

NPI: 1174808794
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: 10/14/2011
Last Update Date: 10/14/2011
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 Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberL14095R
License Number StateLA

VIII. Authorized Official

Name: HOLLY D. CASEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 318-795-0801