1538746284 NPI number — JORDAN HATCH MD

Table of content: JORDAN HATCH MD (NPI 1538746284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538746284 NPI number — JORDAN HATCH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HATCH
Provider First Name:
JORDAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1538746284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5215 HOLY CROSS PKWY
Provider Second Line Business Mailing Address:
PROVIDER SERVICES-ENROLLMENT
Provider Business Mailing Address City Name:
MISHAWAKA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46545-1469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-335-8707
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2930 W CLEVELAND ROAD EXT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46628-6090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-335-8450
Provider Business Practice Location Address Fax Number:
574-335-0780
Provider Enumeration Date:
03/27/2021

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 01092640A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300050952 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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