Provider Demographics
NPI:1215052188
Name:HOLLIDAY, MICHAEL P (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:HOLLIDAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT 2 BOX 120F
Mailing Address - Street 2:
Mailing Address - City:PHILIPPI
Mailing Address - State:WV
Mailing Address - Zip Code:26416
Mailing Address - Country:US
Mailing Address - Phone:304-457-1757
Mailing Address - Fax:304-457-1757
Practice Address - Street 1:RT 2 BOX 120F
Practice Address - Street 2:
Practice Address - City:PHILIPPI
Practice Address - State:WV
Practice Address - Zip Code:26416
Practice Address - Country:US
Practice Address - Phone:304-457-1757
Practice Address - Fax:304-457-1757
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1343174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0157575000Medicaid
WV0157575000Medicaid