Provider Demographics
NPI:1235130717
Name:JOLLEY, BROUGHTON D (MD)
Entity Type:Individual
Prefix:
First Name:BROUGHTON
Middle Name:D
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 535744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-5510
Mailing Address - Country:US
Mailing Address - Phone:844-294-5114
Mailing Address - Fax:865-691-0843
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 5-B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-224-3460
Practice Address - Fax:423-224-3465
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21958207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5704791Medicaid
TN3082522Medicaid
00013859OtherNHC CARE ADMINISTRATORS
050043321OtherRAILROAD MEDICARE
240137OtherANTHEM BCBS
3045725OtherBLUE SHIELD OF TN
TN0100OtherJOHN DEERE
050043321OtherRAILROAD MEDICARE
VA5704791Medicaid
100010643OtherPHP TENNCARE
NC7905767Medicaid
050043321OtherRAILROAD MEDICARE
VA5704791Medicaid