Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | SH069904 | MI |
Y | 208600000X | Surgeon | SH069904 | MI |
N | 2082S0105X | Plastic Hand Surgeon | SH069904 | MI |
NPI | 1811994841 |
---|---|
Provider Name | Dr. Scott Donald Holley |
First Address | Portage, MI 49024-4075 |
Second Address | Portage, MI 49024-4075 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2005 |
Last Update Date | 17/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0C90475 | BLUE CROSS/BLUE SHIELD (01) | MI |
F01433 | (02) | MI |