Provider Demographics
NPI:1598737728
Name:HOLLEY, CHARLES W JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:HOLLEY
Suffix:JR
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 990
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40423-0990
Mailing Address - Country:US
Mailing Address - Phone:859-239-5870
Mailing Address - Fax:
Practice Address - Street 1:216 W WALNUT ST STE A
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1832
Practice Address - Country:US
Practice Address - Phone:859-239-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39268208G00000X
GA041833208G00000X
KY55882208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGA1807Medicaid
GA000707836OMedicaid
GA33BDBHGMedicare UPIN
GA000707836OMedicaid
GAF12992Medicare UPIN