Healthcare Provider Details

I. General information

NPI: 1902848088
Provider Name (Legal Business Name): ERIC A HOLLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR SUITE 230
SALT LAKE CITY UT
84113
US

IV. Provider business mailing address

10150 S CENTINNIAL PWKY SUITE 230
SANDY UT
84070
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-3578
  • Fax: 801-662-3588
Mailing address:
  • Phone: 801-662-3578
  • Fax: 801-662-3588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number6559721
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number46304
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: