Provider Demographics
NPI:1164479911
Name:JOLLY, SURINDAR K (MD)
Entity Type:Individual
Prefix:
First Name:SURINDAR
Middle Name:K
Last Name:JOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4020 VENOY RD
Mailing Address - Street 2:STE#800
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1869
Mailing Address - Country:US
Mailing Address - Phone:734-721-6001
Mailing Address - Fax:734-721-6003
Practice Address - Street 1:4020 VENOY RD
Practice Address - Street 2:STE#800
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1869
Practice Address - Country:US
Practice Address - Phone:734-721-6001
Practice Address - Fax:734-721-6003
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI0557822084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1308261622OtherBLUE CROSS BLUE SHIELD
MI1308209371OtherBLUE CROSS BLUE SHIELD
MI2918602Medicaid
MI2918602Medicaid
MIQ26468001Medicare PIN