Provider Demographics
NPI:1124562483
Name:JORDAN PHYSICIAN ASSOCIATES, INC.
Entity Type:Organization
Organization Name:JORDAN PHYSICIAN ASSOCIATES, INC.
Other - Org Name:BIDH-PLYMOUTH RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-830-2401
Mailing Address - Street 1:275 SANDWICH ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2183
Mailing Address - Country:US
Mailing Address - Phone:508-830-2401
Mailing Address - Fax:508-830-1131
Practice Address - Street 1:275 SANDWICH ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2183
Practice Address - Country:US
Practice Address - Phone:508-830-2401
Practice Address - Fax:508-830-1131
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JORDAN PHYSICIAN ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-06
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110072193WMedicaid