Provider Demographics
NPI:1922069079
Name:JOLLY, THOMAS LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LYNN
Last Name:JOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:390 W SALEM AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5861
Practice Address - Country:US
Practice Address - Phone:336-721-2375
Practice Address - Fax:336-721-2394
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC30659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC46733OtherBCBS OF NC
NCA4895OtherMEDCOST
NC299580OtherMAMSI
ND5188OtherPARTNERS/MEDICARE CHOICE
NC1624882OtherFIRST HEALTH
204154MMedicare PIN
NCC82341Medicare UPIN