MEDICARE: DAVID GLEN HOLLIFIELD MD

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	040411	GA

General Provider Information

NPI Number	:	1588712913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID GLEN HOLLIFIELD MD

Provider Business Mailing Address
First Line	:	2336 WISTERIA DRIVE
Second Line	:	SUITE 430
City	:	SHELLVILLE
State	:	GA
Zip	:	30078
Country	:	US
Telephone Number	:	770-982-4411
Fax Number	:	770-982-3020

Provider Business Practice Location Address
First Line	:	2336 WISTERIA DRIVE
Second Line	:	SUITE 430
City	:	SHELLVILLE
State	:	GA
Zip	:	30078
Country	:	US
Telephone Number	:	770-982-4411
Fax Number	:	770-982-3020

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

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/13/2010

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