Provider Demographics
NPI:1407042922
Name:JOLLY NEUROLOGICAL CLINIC PC
Entity Type:Organization
Organization Name:JOLLY NEUROLOGICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SURINDAR
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-721-6001
Mailing Address - Street 1:4020 VENOY RD
Mailing Address - Street 2:800
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 2:800
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISJ0557822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI130H235340OtherBLUE CROSS BLUE SHIELD
MI2918602Medicaid
MI2918602Medicaid
MI0Q26468Medicare PIN