Provider Demographics
NPI:1972851384
Name:QUINCY JORDAN MD LLC
Entity Type:Organization
Organization Name:QUINCY JORDAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-610-2791
Mailing Address - Street 1:PO BOX 2105
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-2105
Mailing Address - Country:US
Mailing Address - Phone:877-610-2791
Mailing Address - Fax:
Practice Address - Street 1:2350 SOUTH HOUSTON LAKE RD
Practice Address - Street 2:#902
Practice Address - City:KATHLEEN
Practice Address - State:GA
Practice Address - Zip Code:31047-5414
Practice Address - Country:US
Practice Address - Phone:877-610-2791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty