Provider Demographics
NPI:1083716088
Name:ANTHONY L. JORDAN HEALTH CORPORATION
Entity Type:Organization
Organization Name:ANTHONY L. JORDAN HEALTH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR CREDENTILAING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-423-2816
Mailing Address - Street 1:82 HOLLAND STREET
Mailing Address - Street 2:C/O HR CREDENTING DEPT.
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-2131
Mailing Address - Country:US
Mailing Address - Phone:585-423-2816
Mailing Address - Fax:585-423-2853
Practice Address - Street 1:82 HOLLAND STREET
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14605-2131
Practice Address - Country:US
Practice Address - Phone:585-423-5800
Practice Address - Fax:585-423-2890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2701211R261QF0400X
NY261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG0187295590OtherBLUE CHOICE OF ROCHESTER
NY16467AOtherMEDICARE PART B
NY331838OtherMEDICARE PART A
NY00384969Medicaid
NY6613OtherBLUE CROSS OF ROCHESTER
NY331838OtherMEDICARE PART A