Healthcare Provider Details

I. General information

NPI: 1295834810
Provider Name (Legal Business Name): ROBERT M HOLLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 JEFFERSON AVE
PT PLEASANT WV
25550
US

IV. Provider business mailing address

2500 JEFFERSON AVE
PT PLEASANT WV
25550
US

V. Phone/Fax

Practice location:
  • Phone: 304-675-1675
  • Fax: 304-675-3713
Mailing address:
  • Phone: 304-675-1675
  • Fax: 304-675-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11422
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: