Provider Demographics
NPI:1497766554
Name:JEAN A HOLDREN DO PC
Entity Type:Organization
Organization Name:JEAN A HOLDREN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER OF PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLDREN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-386-5004
Mailing Address - Street 1:16687 ST CLAIR AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920
Mailing Address - Country:US
Mailing Address - Phone:330-386-5004
Mailing Address - Fax:330-386-6355
Practice Address - Street 1:16687 ST CLAIR AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920
Practice Address - Country:US
Practice Address - Phone:330-386-5004
Practice Address - Fax:330-386-6355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006738207R00000X
PA0S009111L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F77504Medicare UPIN