Healthcare Provider Details

I. General information

NPI: 1871099499
Provider Name (Legal Business Name): BLAKE RYAN HOLLOWOA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9228 MEDICAL PLAZA DR
CHARLESTON SC
29406-9125
US

IV. Provider business mailing address

335 24TH AVE N
NASHVILLE TN
37203-1503
US

V. Phone/Fax

Practice location:
  • Phone: 843-574-5693
  • Fax: 843-764-4512
Mailing address:
  • Phone: 615-342-0290
  • Fax: 615-342-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number89309
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number71712
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: