Basic Information
| Provider Information | |||||||||
| NPI: | 1871699009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOLLY | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | ARTHUR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WEST AVE | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128666045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185845330 | ||||||||
| FaxNumber: | 5185837663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 12/13/2007 | ||||||||
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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 | 207R00000X | 127194 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00395877 | 05 | NY | MEDICAID |