1144302803 NPI number — WILLIAM J JORDAN PA

Table of content: WILLIAM J JORDAN PA (NPI 1144302803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144302803 NPI number — WILLIAM J JORDAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1144302803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5525 S MARTIN LUTHER KING JR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48911-3546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-394-3175
Provider Business Mailing Address Fax Number:
517-394-7453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
839 S PUTNAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48895-1623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-655-3515
Provider Business Practice Location Address Fax Number:
855-476-0189
Provider Enumeration Date:
10/20/2006

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: 363A00000X , with the licence number:  5601001389 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0N61290008 . This is a "MEDICARE PLUS BLUE-MEDICARE ADVANTAGE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1153313120 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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