Provider Demographics
NPI:1568711596
Name:ANTHONY L. JORDAN HEALTH CORPORATION
Entity Type:Organization
Organization Name:ANTHONY L. JORDAN HEALTH CORPORATION
Other - Org Name:JORDAN HEALTH AT COMMUNITY PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARBIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-423-5800
Mailing Address - Street 1:82 HOLLAND ST
Mailing Address - Street 2:ALJHC
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-2131
Mailing Address - Country:US
Mailing Address - Phone:585-423-5800
Mailing Address - Fax:585-423-2890
Practice Address - Street 1:151 PARSELLS AVE
Practice Address - Street 2:JORDAN HEALTH AT COMMUNITY PLACE
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609
Practice Address - Country:US
Practice Address - Phone:585-454-7530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTHONY L. JORDAN HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-06
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY331838OtherMEDICARE PART A PTAN
NY16467AOtherMEDICARE PART B PTAN
NY04065629Medicaid
NY16467AOtherMEDICARE PART B
NYG0187295590OtherBLUE CHOICE OF ROCHESTER