Provider Demographics
NPI:1467618694
Name:JORDAN, MARY CHISHOLM (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHISHOLM
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44199 DEQUINDRE RD
Mailing Address - Street 2:SUITE 415
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1128
Mailing Address - Country:US
Mailing Address - Phone:248-964-6061
Mailing Address - Fax:248-964-6054
Practice Address - Street 1:44199 DEQUINDRE RD
Practice Address - Street 2:SUITE 415
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1128
Practice Address - Country:US
Practice Address - Phone:248-964-6061
Practice Address - Fax:248-964-6054
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010084207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology