Provider Demographics
NPI:1528037645
Name:SMOLLER, JORDAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:W
Last Name:SMOLLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0835
Mailing Address - Fax:617-726-0850
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:PSYCHIATRY OUTPATIENT DEPARTMENT WAC 8
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-724-0835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2013-01-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA788482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ18506OtherBCBS MA
MA3175065Medicaid
MA759971OtherTUFTS HEALTH PLAN
MAA21166Medicare ID - Type Unspecified
MA759971OtherTUFTS HEALTH PLAN