Provider Demographics
NPI:1174808794
Name:HOLLY D. CASEY, MD. A PROFESSIONAL MEDICAL CORP.
Entity type:Organization
Organization Name:HOLLY D. CASEY, MD. A PROFESSIONAL MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-795-0801
Mailing Address - Street 1:8600 FERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-795-0801
Mailing Address - Fax:318-795-9492
Practice Address - Street 1:8600 FERN AVENUE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-795-0801
Practice Address - Fax:318-795-9492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL14095R2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1184306Medicaid
LA1184306Medicaid
LAH00324Medicare UPIN