Provider Demographics
NPI:1447203500
Name:JORDAN HOSPITAL ANESTHESIA ASSOCIATES, PC
Entity Type:Organization
Organization Name:JORDAN HOSPITAL ANESTHESIA ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-747-7246
Mailing Address - Street 1:68 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MA
Mailing Address - Zip Code:02330-1128
Mailing Address - Country:US
Mailing Address - Phone:508-747-7246
Mailing Address - Fax:508-747-7256
Practice Address - Street 1:68 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CARVER
Practice Address - State:MA
Practice Address - Zip Code:02330-1128
Practice Address - Country:US
Practice Address - Phone:508-747-7246
Practice Address - Fax:508-747-7256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1447203500OtherBLUE CROSS BLUE SHIELD
MA9757031Medicaid