1902078066 NPI number — MR. JORDAN CHRISTOPHER SMALLWOOD M.D.

Table of content: MR. JORDAN CHRISTOPHER SMALLWOOD M.D. (NPI 1902078066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902078066 NPI number — MR. JORDAN CHRISTOPHER SMALLWOOD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALLWOOD
Provider First Name:
JORDAN
Provider Middle Name:
CHRISTOPHER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902078066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603725
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-3725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-575-2625
Provider Business Mailing Address Fax Number:
828-350-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 MCDOWELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28801-4104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-255-3749
Provider Business Practice Location Address Fax Number:
828-254-9925
Provider Enumeration Date:
03/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  ME 116755 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: 2022-02522 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NNN346A . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1902078066 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".