1093709156 NPI number — DR. THOMAS JOHN JOLY MD PHD

Table of content: MARTHA MOREIRAS (NPI 1164850756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093709156 NPI number — DR. THOMAS JOHN JOLY MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOLY
Provider First Name:
THOMAS
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
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:
1093709156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
241 CORPORATE BLVD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23502-4975
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-622-2200
Provider Business Mailing Address Fax Number:
757-622-4866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
241 CORPORATE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23502-4954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-622-2200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2005

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: 207W00000X , with the licence number:  0101237897 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00233084 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5901573 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 96223 . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 181580 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1093709156 . This is a "VIRGINIA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5391774 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1093709156 . This is a "TRICARE/TRICARE FOR LIFE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1093709156 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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