Healthcare Provider Details

I. General information

NPI: 1366503195
Provider Name (Legal Business Name): NEERAJ JOLLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 1159
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST SUITE 1159
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5020
  • Fax: 312-563-7475
Mailing address:
  • Phone: 312-942-5020
  • Fax: 312-563-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0002X
TaxonomyAdult Congenital Heart Disease Physician
License Number036100233
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036100233
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036-100233
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: