Provider Demographics
NPI:1629373782
Name:JORDAN MEDICAL P.A.
Entity Type:Organization
Organization Name:JORDAN MEDICAL P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHIAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-295-8826
Mailing Address - Street 1:114 W 3RD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-4705
Mailing Address - Country:US
Mailing Address - Phone:763-295-8826
Mailing Address - Fax:763-295-1900
Practice Address - Street 1:7266 COUNTY ROAD 37 NE
Practice Address - Street 2:
Practice Address - City:ST. MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-3007
Practice Address - Country:US
Practice Address - Phone:763-295-4789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25273207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080007391Medicare PIN
MND80192Medicare UPIN