1043314685 NPI number — AMY S JOLLIFF MD

Table of content: AMY S JOLLIFF MD (NPI 1043314685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043314685 NPI number — AMY S JOLLIFF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOLLIFF
Provider First Name:
AMY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1043314685
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 E MILLTOWN RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
WOOSTER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44691
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-345-8060
Provider Business Mailing Address Fax Number:
330-345-5983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 E MILLTOWN RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
WOOSTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-345-8060
Provider Business Practice Location Address Fax Number:
330-345-5983
Provider Enumeration Date:
09/12/2006

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:  35058875 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9304461 . This is a "MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2123062 . This is a "MEDICAID GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0835967 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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