Provider Demographics
NPI:1235325994
Name:HOLLEY, STEPHEN REESE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:REESE
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 1:3023 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5200
Mailing Address - Country:US
Mailing Address - Phone:310-866-2964
Mailing Address - Fax:618-351-4821
Practice Address - Street 1:2 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-684-3156
Practice Address - Fax:618-529-0522
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118873207R00000X
CAA100941207R00000X
IL036.118873208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1009410OtherBCBS OF CA
CA0A1009410Medicaid
IL214881Medicare Oscar/Certification
CAWA100941AMedicare PIN