Provider Demographics
NPI:1326220591
Name:J MELBURN D HOLMES
Entity Type:Organization
Organization Name:J MELBURN D HOLMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-863-5262
Mailing Address - Street 1:PO BOX 665
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:AL
Mailing Address - Zip Code:36274-0665
Mailing Address - Country:US
Mailing Address - Phone:334-863-5262
Mailing Address - Fax:334-863-5264
Practice Address - Street 1:32 MEDICAL DR
Practice Address - Street 2:STE 7
Practice Address - City:ROANOKE
Practice Address - State:AL
Practice Address - Zip Code:36274-2421
Practice Address - Country:US
Practice Address - Phone:334-863-5262
Practice Address - Fax:334-863-5264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529922930Medicaid
AL51555463Medicare PIN