Provider Demographics
NPI:1790898070
Name:HOLT FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:HOLT FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-694-1466
Mailing Address - Street 1:4378 HOLT RD
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-1666
Mailing Address - Country:US
Mailing Address - Phone:517-694-1466
Mailing Address - Fax:517-694-5142
Practice Address - Street 1:4378 HOLT RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1666
Practice Address - Country:US
Practice Address - Phone:517-694-1466
Practice Address - Fax:517-694-5142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080C364770OtherBCBS GROUP ID
MI080C364770OtherBCBS GROUP ID
MIOC36477Medicare PIN