Provider Demographics
NPI:1225015696
Name:HOLLEY, PAUL S (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:HOLLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4936 MAIN ST
Mailing Address - Street 2:PO BOX 470
Mailing Address - City:BEMUS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:14712-9667
Mailing Address - Country:US
Mailing Address - Phone:716-386-2414
Mailing Address - Fax:716-386-2437
Practice Address - Street 1:4936 MAIN ST
Practice Address - Street 2:
Practice Address - City:BEMUS POINT
Practice Address - State:NY
Practice Address - Zip Code:14712-9667
Practice Address - Country:US
Practice Address - Phone:716-386-2414
Practice Address - Fax:716-386-2437
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204064207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010198101OtherUNIVERA PROVIDER NUMBER
NY0109568OtherINDEPENDENT HEALTH
NY000524400003OtherBC WESTERN NY PROVIDER #
NY01669929Medicaid
NY01669929Medicaid
NY00010198101OtherUNIVERA PROVIDER NUMBER