Provider Demographics
NPI:1508817248
Name:HOLZER CLINIC, LLC
Entity Type:Organization
Organization Name:HOLZER CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:CANADY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-446-5051
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5385
Mailing Address - Fax:740-446-5310
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5385
Practice Address - Fax:740-446-5310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152WV0400X, 246RM2200X, 261QM1300X, 261QM1300X
OH0614AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Multi-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4046428Medicaid
WV0006817002Medicaid
0416420001Medicare NSC
OH9924211Medicare PIN
WV9343821Medicare PIN
WV0006817002Medicaid
OH4046428Medicaid
OH9924211Medicare PIN
OH2228440OtherMEDICAID - JACKSON AMBULATORY SURGERY CENTER
WV0006817003Medicaid
WV0006817005Medicaid
WV6902000000Medicaid
OH3612211OtherMEDICARE ASC -GALLIPOLIS
WV3810009743Medicaid