Provider Demographics
NPI:1073518270
Name:HOLMAN, ROGER (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:HOLMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 W RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1305
Mailing Address - Country:US
Mailing Address - Phone:616-837-9777
Mailing Address - Fax:616-837-7813
Practice Address - Street 1:675 W RANDALL ST
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1305
Practice Address - Country:US
Practice Address - Phone:616-837-9777
Practice Address - Fax:616-837-7813
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006733207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N27520OtherMEDICARE MCUG GROUP
MIN27520004OtherMEDICARE MGUC INDIVIDUAL
MI005703574OtherBCBSMI
MI0027003OtherPRIORITY HEALTH HMO
MI4313667Medicaid
MIP57675OtherBLUES HMO'S
RH006733OtherBCBS
MI112730992Medicaid
MI0027003OtherPRIORITY HEALTH HMO
MI0N27520OtherMEDICARE MCUG GROUP
MIE26596Medicare UPIN