MEDICARE: HOLLY D'LANA VON GRUENIGEN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	03704	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215220827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY D'LANA VON GRUENIGEN D.O.

Provider Business Mailing Address
First Line	:	PO BOX 1080
Second Line	:
City	:	BURKESVILLE
State	:	KY
Zip	:	42717-1080
Country	:	US
Telephone Number	:	270-864-1472
Fax Number	:	270-864-1693

Provider Business Practice Location Address
First Line	:	404 STEVE DR
Second Line	:
City	:	RUSSELL SPRINGS
State	:	KY
Zip	:	42642-4622
Country	:	US
Telephone Number	:	270-866-3161
Fax Number	:	270-866-3163

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	09/19/2019

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