Provider Demographics
NPI:1457448490
Name:JORDAN, BLAIR PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:PHILIP
Last Name:JORDAN
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 1:508 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2953
Mailing Address - Country:US
Mailing Address - Phone:936-760-4600
Mailing Address - Fax:936-760-4601
Practice Address - Street 1:508 MEDICAL CENTER BLVD
Practice Address - Street 2:STE 200
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2953
Practice Address - Country:US
Practice Address - Phone:936-760-4600
Practice Address - Fax:936-760-4601
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8180208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098632501Medicaid
GA20016066Medicare PIN
TXC17629Medicare UPIN
TX098632501Medicaid