Provider Demographics
NPI:1538154018
Name:HOLM, BYRON M (MD)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:M
Last Name:HOLM
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 1:2855 MILLER DR STE 205
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8093
Mailing Address - Country:US
Mailing Address - Phone:574-286-0200
Mailing Address - Fax:888-247-3121
Practice Address - Street 1:2855 MILLER DR STE 205
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8093
Practice Address - Country:US
Practice Address - Phone:574-936-7777
Practice Address - Fax:888-247-3121
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024911A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000729125OtherANTHEM BCBS
IN100173410Medicaid
INM400055252OtherMEDICARE PTAN#
IN100173410AMedicaid
IN100173410AMedicaid
IN100173410Medicaid