Provider Demographics
NPI:1821075508
Name:JORDAN, RICHARD MONTGOMERY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MONTGOMERY
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SUMMIT CROSSING PL
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2176
Mailing Address - Country:US
Mailing Address - Phone:704-867-8021
Mailing Address - Fax:704-864-4606
Practice Address - Street 1:620 SUMMIT CROSSING PL
Practice Address - Street 2:SUITE 106
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2176
Practice Address - Country:US
Practice Address - Phone:704-867-8021
Practice Address - Fax:704-864-4606
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC309232085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
72386OtherMEDCOST
47484OtherBLUE CROSS BLUE SHIELD
2137652OtherAETNA HMO
4629496OtherAETNA PPO
NC8947484Medicaid
SCN30923Medicaid
300068233OtherRAILROAD MEDICARE
1642994OtherUNITED HEALTHCARE
6677OtherPARTNERS
47484OtherBLUE CROSS BLUE SHIELD
213411Medicare ID - Type Unspecified