Provider Demographics
NPI:1003153321
Name:JO-ANN N. BOLLI, M. D., P.S.C.
Entity Type:Organization
Organization Name:JO-ANN N. BOLLI, M. D., P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JO-ANN
Authorized Official - Middle Name:NADEAU
Authorized Official - Last Name:BOLLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-653-4070
Mailing Address - Street 1:308 S WASHINGTON ST STE 201
Mailing Address - Street 2:P. O. BOX 123
Mailing Address - City:CLINTON
Mailing Address - State:KY
Mailing Address - Zip Code:42031-1347
Mailing Address - Country:US
Mailing Address - Phone:270-653-4070
Mailing Address - Fax:270-653-4007
Practice Address - Street 1:308 S WASHINGTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CLINTON
Practice Address - State:KY
Practice Address - Zip Code:42031-1340
Practice Address - Country:US
Practice Address - Phone:270-653-4070
Practice Address - Fax:270-653-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28789261QP2300X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64287899Medicaid
KY64287899Medicaid