Basic Information
| Provider Information | |||||||||
| NPI: | 1235130717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOLLEY | ||||||||
| FirstName: | BROUGHTON | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 535744 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303535510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442945114 | ||||||||
| FaxNumber: | 8656910843 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 W RAVINE RD | ||||||||
| Address2: | SUITE 5-B | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243460 | ||||||||
| FaxNumber: | 4232243465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 21958 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 5704791 | 05 | VA | MEDICAID | 3082522 | 05 | TN | MEDICAID | 00013859 | 01 | NHC CARE ADMINISTRATORS | OTHER | 050043321 | 01 | RAILROAD MEDICARE | OTHER | 240137 | 01 | ANTHEM BCBS | OTHER | 3045725 | 01 | BLUE SHIELD OF TN | OTHER | TN0100 | 01 | JOHN DEERE | OTHER |