1659427615 NPI number — TOM HOLLEY, MD, INC.

Table of content: (NPI 1659427615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659427615 NPI number — TOM HOLLEY, MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOM HOLLEY, MD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659427615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1216 ALCAZAR ST NE
Provider Second Line Business Mailing Address:
GOLDSMITH
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87110-7108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-232-9516
Provider Business Mailing Address Fax Number:
505-232-9516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1216 ALCAZAR ST NE
Provider Second Line Business Practice Location Address:
GOLDSMITH
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110-7108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-232-9516
Provider Business Practice Location Address Fax Number:
505-232-9516
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLEY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER, PSYCHIATRIST
Authorized Official Telephone Number:
505-232-9516

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  77-45 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 77-45 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 25478 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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