Provider Demographics
NPI:1548285612
Name:MAES, HOLLY MAE (MD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:MAE
Last Name:MAES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4363
Mailing Address - Country:US
Mailing Address - Phone:217-442-0433
Mailing Address - Fax:217-442-0485
Practice Address - Street 1:737 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4363
Practice Address - Country:US
Practice Address - Phone:217-442-0433
Practice Address - Fax:217-442-0485
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113601208000000X
IL036113601208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361136011Medicaid
IL371548OtherBLUE CROSS BLUE SHIELD
ILF51038Medicare UPIN
IL0361136011Medicaid
IL371548OtherBLUE CROSS BLUE SHIELD