Provider Demographics
NPI:1801840442
Name:JOLLY, BEN L (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:L
Last Name:JOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:515 E PROMENADE ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-2966
Mailing Address - Country:US
Mailing Address - Phone:573-582-6831
Mailing Address - Fax:573-582-3220
Practice Address - Street 1:515 E PROMENADE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2966
Practice Address - Country:US
Practice Address - Phone:573-582-6831
Practice Address - Fax:573-582-3220
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO36087207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000009537Medicare ID - Type Unspecified
1079750001Medicare NSC
MOA11936Medicare UPIN