1730594359 NPI number — JORDAN M SIEWERT DO

Table of content: JORDAN M SIEWERT DO (NPI 1730594359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730594359 NPI number — JORDAN M SIEWERT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIEWERT
Provider First Name:
JORDAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1730594359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 N SUMMIT ST FL 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43604-1531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-291-8701
Provider Business Mailing Address Fax Number:
419-479-3298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-291-2051
Provider Business Practice Location Address Fax Number:
419-479-6952
Provider Enumeration Date:
06/23/2014

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: 207Q00000X , with the licence number:  5101025751 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 34012356 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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