Provider Demographics
NPI:1982662896
Name:JORDAN & ASSOCIATES GASTROENTEROLOGY, PA
Entity Type:Organization
Organization Name:JORDAN & ASSOCIATES GASTROENTEROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHERWOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-938-4404
Mailing Address - Street 1:649 GUY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-4224
Mailing Address - Country:US
Mailing Address - Phone:919-938-4404
Mailing Address - Fax:919-938-3055
Practice Address - Street 1:649 GUY RD STE 200
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-4224
Practice Address - Country:US
Practice Address - Phone:919-938-4404
Practice Address - Fax:919-938-3055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000842207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891324UMedicaid
NC1324UOtherBLUE CROSS BLUE SHIELD
NC2330222Medicare ID - Type Unspecified