Provider Demographics
NPI:1962465435
Name:BOLEY, JERRY JOE (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:JOE
Last Name:BOLEY
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 1:4112 MONROE RD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45828-9250
Mailing Address - Country:US
Mailing Address - Phone:614-580-8563
Mailing Address - Fax:
Practice Address - Street 1:4112 MONROE RD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45828-9250
Practice Address - Country:US
Practice Address - Phone:614-580-8563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070190B207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
289254OtherBLACK LUNG
1330778OtherCIGNA
OH060038975OtherRAILROAD MEDICARE
12723OtherNATIONWIDE
OH0307108Medicaid
060038975OtherRAILROAD MEDICARE
0000000014726OtherANTHEM BCBS
2500965OtherUNITED HEALTHCARE OF OHIO
2500965OtherUNITED HEALTHCARE OF OHIO
OH060038975OtherRAILROAD MEDICARE
B00803837Medicare ID - Type Unspecified