Provider Demographics
NPI:1235134578
Name:HOLTGREWE, MICHAEL RAY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:HOLTGREWE
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:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:WOUND CARE CENTER
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-374-1623
Practice Address - Fax:740-568-5355
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.043477208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000728056OtherANTHEM
WV0041480000Medicaid
OH000000727930OtherANTHEM
OHP01254615OtherRAILROAD MEDICARE - MHCPI
OH0397324Medicaid
0520695Medicare PIN
D71720Medicare UPIN
OH000000727930OtherANTHEM
OH0397324Medicaid