Healthcare Provider Details

I. General information

NPI: 1427321892
Provider Name (Legal Business Name): TIPHANY ALEXANDREA JOLLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SHELBURNE ROAD
STAMFORD CT
06902
US

IV. Provider business mailing address

7125 ORCHARD LAKE RD STE 120
WEST BLOOMFIELD MI
48322-3627
US

V. Phone/Fax

Practice location:
  • Phone: 203-276-7777
  • Fax:
Mailing address:
  • Phone: 248-780-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number78050
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number78050
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: