Healthcare Provider Details

I. General information

NPI: 1659941144
Provider Name (Legal Business Name): SAMUEL HOLECHEK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N WOLFE ST
BALTIMORE MD
21205-2110
US

IV. Provider business mailing address

23 YOGURT LN
BALTIMORE MD
21231-1825
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-4766
  • Fax:
Mailing address:
  • Phone: 443-244-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR235490
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: