Provider Demographics
NPI:1568469658
Name:JORDAN, EDWARD MATHEW (PT)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:MATHEW
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1859
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1859
Mailing Address - Country:US
Mailing Address - Phone:440-341-6520
Mailing Address - Fax:410-341-6526
Practice Address - Street 1:32071 BEAVER RUN DR
Practice Address - Street 2:STE B
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-1773
Practice Address - Country:US
Practice Address - Phone:440-341-6520
Practice Address - Fax:410-341-6526
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q00754Medicare UPIN
868M628FMedicare ID - Type Unspecified