Provider Demographics
NPI:1174562599
Name:HOLAN, KEITH R (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:HOLAN
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:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44222-0609
Mailing Address - Country:US
Mailing Address - Phone:330-923-6606
Mailing Address - Fax:330-923-8090
Practice Address - Street 1:3033 STATE RD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-3614
Practice Address - Country:US
Practice Address - Phone:330-945-4739
Practice Address - Fax:330-945-7381
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043324H207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0419210Medicaid
4159453Medicare PIN
4159451Medicare PIN
4159452Medicare PIN
C01747Medicare UPIN
P00321074Medicare PIN