Provider Demographics
NPI:1164757969
Name:BRIAN A. STOLLEY MD, INC
Entity Type:Organization
Organization Name:BRIAN A. STOLLEY MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:STOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-879-4909
Mailing Address - Street 1:41 E LIPOA ST
Mailing Address - Street 2:SUITE 21
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-8148
Mailing Address - Country:US
Mailing Address - Phone:808-879-4909
Mailing Address - Fax:808-875-8595
Practice Address - Street 1:41 E LIPOA ST
Practice Address - Street 2:SUITE 21
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-8148
Practice Address - Country:US
Practice Address - Phone:808-879-4909
Practice Address - Fax:808-875-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD12343208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH65221Medicare UPIN