Provider Demographics
NPI:1093742322
Name:EDWARD A HOLLENBERG MD PC
Entity Type:Organization
Organization Name:EDWARD A HOLLENBERG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-229-5995
Mailing Address - Street 1:29255 NORTHWESTERN HWY
Mailing Address - Street 2:STE 302
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1018
Mailing Address - Country:US
Mailing Address - Phone:248-358-0155
Mailing Address - Fax:248-358-0153
Practice Address - Street 1:8589 W GRAND RIVER AVE
Practice Address - Street 2:STE E
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-4335
Practice Address - Country:US
Practice Address - Phone:810-229-5995
Practice Address - Fax:248-358-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041391207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID