1922069079 NPI number — DR. THOMAS LYNN JOLLY MD

Table of content: DR. THOMAS LYNN JOLLY MD (NPI 1922069079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922069079 NPI number — DR. THOMAS LYNN JOLLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOLLY
Provider First Name:
THOMAS
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922069079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 W SALEM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27101-5861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-721-2375
Provider Business Practice Location Address Fax Number:
336-721-2394
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  30659 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 46733 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: A4895 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 299580 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5188 . This is a "PARTNERS/MEDICARE CHOICE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 1624882 . This is a "FIRST HEALTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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