Provider Demographics
NPI:1649324930
Name:JOLLY, ATHENA T (MD)
Entity type:Individual
Prefix:DR
First Name:ATHENA
Middle Name:T
Last Name:JOLLY
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:570-326-8723
Mailing Address - Fax:570-326-8922
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1909
Practice Address - Country:US
Practice Address - Phone:570-320-7444
Practice Address - Fax:570-320-7445
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0000709207R00000X
PAMD043019E2083X0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC1-0000709OtherPROFESSIONAL LICENSE
DE1000030188Medicaid
PAMD043019EOtherLICENSE
PAC48634Medicare UPIN