Provider Demographics
NPI:1467415117
Name:JORDAN, MARLON D (MD)
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:D
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 1:1418 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-2638
Mailing Address - Country:US
Mailing Address - Phone:618-240-2740
Mailing Address - Fax:618-263-6479
Practice Address - Street 1:1418 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-2638
Practice Address - Country:US
Practice Address - Phone:618-240-2740
Practice Address - Fax:618-263-6479
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030224A207RC0000X
IL036082355207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000042524OtherANTHEM
KY64756620Medicaid
IN100343920AMedicaid
IN178910AMedicare PIN
000000042524OtherANTHEM
C24308Medicare UPIN
IL060058729Medicare PIN
KY0255515Medicare PIN
KY64756620Medicaid
C24308Medicare UPIN