Basic Information
| Provider Information | |||||||||
| NPI: | 1811933583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLY | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793516 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 6404 ROTHMAN RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468351366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604866197 | ||||||||
| FaxNumber: | 2604869862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01042777A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200009260 | 05 | IN | MEDICAID | 000000206199 | 01 | BLUE CROSS | OTHER |