=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902848088
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC A HOLLEY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N MARIO CAPECCHI DR SUITE 230
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-662-3578
-----------------------------------------------------
Fax | 801-662-3588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10150 S CENTINNIAL PWKY SUITE 230
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-662-3578
-----------------------------------------------------
Fax | 801-662-3588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP3000X
-----------------------------------------------------
Taxonomy Name | Pediatric Anesthesiology Physician
-----------------------------------------------------
License Number | 6559721
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 46304
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------