Provider Demographics
NPI:1003987538
Name:BYRON M. HOLM, MD
Entity Type:Organization
Organization Name:BYRON M. HOLM, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-936-7777
Mailing Address - Street 1:2855 MILLER DR
Mailing Address - Street 2:SUITE 117
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8091
Mailing Address - Country:US
Mailing Address - Phone:574-936-7777
Mailing Address - Fax:574-941-1072
Practice Address - Street 1:2855 MILLER DR
Practice Address - Street 2:SUITE 117
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8091
Practice Address - Country:US
Practice Address - Phone:574-936-7777
Practice Address - Fax:574-941-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200276050Medicaid
IN200276050Medicaid