Provider Demographics
NPI:1205255528
Name:TALLEY, JORDAN H (DO)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:H
Last Name:TALLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 603484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3484
Mailing Address - Country:US
Mailing Address - Phone:803-765-1838
Mailing Address - Fax:803-765-1732
Practice Address - Street 1:1840 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2808
Practice Address - Country:US
Practice Address - Phone:540-536-8000
Practice Address - Fax:540-536-7780
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2024031393207L00000X
SC87911207L00000X
VA0102205112207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology