Provider Demographics
NPI:1780179259
Name:PRICE, JORDAN T (DO)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:T
Last Name:PRICE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 LEAHY ST STE 315A
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5543
Mailing Address - Country:US
Mailing Address - Phone:231-727-5244
Mailing Address - Fax:231-727-5223
Practice Address - Street 1:1700 CLINTON ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5502
Practice Address - Country:US
Practice Address - Phone:231-726-3511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025317207P00000X
MI5101024330390200000X
AZ009468207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101025317OtherLICENSE