Provider Demographics
NPI:1083784235
Name:JORDAN, CHARLES ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ANDREW
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 W MAIN ST
Mailing Address - Street 2:SUITE M
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3351
Mailing Address - Country:US
Mailing Address - Phone:615-453-1252
Mailing Address - Fax:615-453-1286
Practice Address - Street 1:1029 W MAIN ST
Practice Address - Street 2:SUITE M
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3351
Practice Address - Country:US
Practice Address - Phone:615-453-1252
Practice Address - Fax:615-453-1286
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD019767208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNE89251Medicare UPIN