Provider Demographics
NPI:1295834810
Name:HOLLEY, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
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 1:2500 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550
Mailing Address - Country:US
Mailing Address - Phone:304-675-1675
Mailing Address - Fax:304-675-3713
Practice Address - Street 1:2500 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:PT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550
Practice Address - Country:US
Practice Address - Phone:304-675-1675
Practice Address - Fax:304-675-3713
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0050184000Medicaid
WV001720019OtherBCBS
WV55060926800OtherWV COMPENSATION
OH0730678Medicaid
WV550609268OtherAETNA
WVH00626141Medicare PIN
WV001720019OtherBCBS
WV550609268OtherAETNA