Provider Demographics
NPI:1447218078
Name:JORDAN, RANDI M (PT)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1310
Mailing Address - Country:US
Mailing Address - Phone:413-644-9474
Mailing Address - Fax:
Practice Address - Street 1:35 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1310
Practice Address - Country:US
Practice Address - Phone:413-644-9474
Practice Address - Fax:413-644-9474
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5865208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y66705Medicare UPIN
Y66705Medicare PIN