1811961519 NPI number — JOLLY THOMAS ANP

Table of content: JOLLY THOMAS ANP (NPI 1811961519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811961519 NPI number — JOLLY THOMAS ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
JOLLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
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:
1811961519
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 660599
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75266-0599
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:
1936 AMELIA CT
Provider Second Line Business Practice Location Address:
GERIATRIC CENTER & SENIOR SERVICES
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75235-7706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-590-8369
Provider Business Practice Location Address Fax Number:
214-590-8780
Provider Enumeration Date:
02/17/2006

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: 363LA2200X , with the licence number:  593284 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8N9803 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 179001601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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