Provider Demographics
NPI:1255392213
Name:HOLLEY, SHAY (MD)
Entity type:Individual
Prefix:
First Name:SHAY
Middle Name:
Last Name:HOLLEY
Suffix:
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 1:144 S 500 E
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5475 S 500 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6905
Practice Address - Country:US
Practice Address - Phone:801-479-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275093-1205207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT930085279OtherRAILROAD
UTD0576Medicaid
UTD0576Medicaid
UT$$$$$$$$$10001OtherBC/BS
UT005567205Medicare ID - Type Unspecified5475 S 500 E, OGDEN
UT$$$$$$$$$11001OtherBC/BS
UT$$$$$$$$$10001OtherBC/BS