Provider Demographics
NPI:1669479648
Name:MCCOY, HOLLY KELLAM
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:KELLAM
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1142
Mailing Address - Country:US
Mailing Address - Phone:502-348-5968
Mailing Address - Fax:502-349-0963
Practice Address - Street 1:201 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1142
Practice Address - Country:US
Practice Address - Phone:502-348-5968
Practice Address - Fax:502-349-0963
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH57718Medicare UPIN