Healthcare Provider Details

I. General information

NPI: 1164479911
Provider Name (Legal Business Name): SURINDAR K JOLLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 VENOY RD STE#800
WAYNE MI
48184-1869
US

IV. Provider business mailing address

4020 VENOY RD STE#800
WAYNE MI
48184-1869
US

V. Phone/Fax

Practice location:
  • Phone: 734-721-6001
  • Fax: 734-721-6003
Mailing address:
  • Phone: 734-721-6001
  • Fax: 734-721-6003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number055782
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: