Healthcare Provider Details

I. General information

NPI: 1235134578
Provider Name (Legal Business Name): MICHAEL RAY HOLTGREWE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST WOUND CARE CENTER
MARIETTA OH
45750-1635
US

IV. Provider business mailing address

PO BOX 449
MARIETTA OH
45750-0449
US

V. Phone/Fax

Practice location:
  • Phone: 740-374-1623
  • Fax: 740-568-5355
Mailing address:
  • Phone: 740-374-4500
  • Fax: 740-374-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35.043477
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: