Provider Demographics
NPI:1225124936
Name:BAILEY, JORDAN LYLE (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LYLE
Last Name:BAILEY
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 1:151 N 4TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6300
Mailing Address - Country:US
Mailing Address - Phone:208-269-7147
Mailing Address - Fax:208-416-6522
Practice Address - Street 1:151 N 4TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6300
Practice Address - Country:US
Practice Address - Phone:208-269-7147
Practice Address - Fax:208-416-6522
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID76704OtherBLUE CROSS
ID807222600Medicaid
ID76704OtherBLUE CROSS
IDI04163Medicare UPIN