Provider Demographics
NPI:1376742411
Name:HOLLOWAY, JEFFREY P (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:P
Last Name:HOLLOWAY
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-434-7950
Mailing Address - Fax:803-434-8606
Practice Address - Street 1:9 MEDICAL PARK,
Practice Address - Street 2:SUITE 200-A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6878
Practice Address - Country:US
Practice Address - Phone:803-434-7950
Practice Address - Fax:803-434-7981
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29756207QS0010X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC297562Medicaid
SCAA69552389OtherMEDICARE PTAN
SCAA69552488Medicare PIN