Provider Demographics
NPI:1588698518
Name:HOLLADAY, CONNIE J (MC)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:HOLLADAY
Suffix:
Gender:F
Credentials:MC
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 37087
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3807
Mailing Address - Country:US
Mailing Address - Phone:828-687-6282
Mailing Address - Fax:828-687-6285
Practice Address - Street 1:438 E. VANN ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-7202
Practice Address - Country:US
Practice Address - Phone:423-278-1700
Practice Address - Fax:423-278-1712
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15684207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518493Medicaid
MS0018811Medicaid
TN4009043OtherBCBS OF TN
TN3028983Medicare ID - Type UnspecifiedMEDICARE
MS0018811Medicaid
TN102I112001Medicare PIN