Provider Demographics
NPI:1356506455
Name:ROBERT W. JORDAN MD PC
Entity Type:Organization
Organization Name:ROBERT W. JORDAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-295-7200
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7667
Mailing Address - Country:US
Mailing Address - Phone:801-295-7200
Mailing Address - Fax:801-295-4930
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 400
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7667
Practice Address - Country:US
Practice Address - Phone:801-295-7200
Practice Address - Fax:801-295-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT166068-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD07361Medicare UPIN