Provider Demographics
NPI:1134198526
Name:BOLLI, JO ANN N (MD)
Entity type:Individual
Prefix:
First Name:JO ANN
Middle Name:N
Last Name:BOLLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 ASHEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37743-5401
Mailing Address - Country:US
Mailing Address - Phone:423-626-1521
Mailing Address - Fax:423-626-1523
Practice Address - Street 1:308 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:KY
Practice Address - Zip Code:42031-1340
Practice Address - Country:US
Practice Address - Phone:270-254-3021
Practice Address - Fax:270-254-3023
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43737208D00000X, 207VG0400X, 208D00000X
KY28789208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4046827Medicaid
TN4143318OtherBCBS
KY000000502868OtherBCBS
KY0965203Medicare PIN
KY000000502868OtherBCBS
KY64287899Medicaid
KY000000502868OtherBCBS