1669467791 NPI number — GRANT K HOLLAND MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669467791 NPI number — GRANT K HOLLAND MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

HOLLAND

Provider First Name:

GRANT

Provider Middle Name:

K

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1669467791

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/04/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 27128

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SALT LAKE CITY

Provider Business Mailing Address State Name:

UT

Provider Business Mailing Address Postal Code:

84127-0128

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

801-387-3400

Provider Business Mailing Address Fax Number:

801-387-3420

Provider First Line Business Practice Location Address:

4403 HARRISON BLVD

Provider Second Line Business Practice Location Address:

SUITE 3400

Provider Business Practice Location Address City Name:

OGDEN

Provider Business Practice Location Address State Name:

UT

Provider Business Practice Location Address Postal Code:

84403-3271

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

801-387-3400

Provider Business Practice Location Address Fax Number:

801-387-3420

Provider Enumeration Date:

09/14/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0000X , with the licence number:  165831-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 25-00066 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: QM0000006789 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: PRA01702 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
• Identifier: 107006006103 . This is a "SELECTHEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 21114 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 90219 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 204985513001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
• Identifier: 204985513GKH . This is a "EMIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: DUUX3 . This is a "BC OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
• Identifier: 611697900 . This is a "USDOL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: P00339377 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
• Identifier: 20498551384403A002 . This is a "TRIWEST" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".