Provider Demographics
NPI:1518498054
Name:RUTHERFORD, JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:RUTHERFORD
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 1:241 W COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630
Mailing Address - Country:US
Mailing Address - Phone:256-764-9522
Mailing Address - Fax:256-764-1139
Practice Address - Street 1:421 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-5520
Practice Address - Country:US
Practice Address - Phone:256-764-9522
Practice Address - Fax:256-764-1139
Is Sole Proprietor?:No
Enumeration Date:2017-03-26
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143517208000000X
MST-3420208000000X
390200000X
AL42434208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL265009Medicaid
AL1518498054OtherBLUE CROSS AND BLUE SHIELD