Provider Demographics
NPI:1669606992
Name:JORDAN, BENJAMIN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD
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 1:601 DODDS AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3911
Mailing Address - Country:US
Mailing Address - Phone:866-730-5619
Mailing Address - Fax:423-698-3622
Practice Address - Street 1:210 25TH AVE N
Practice Address - Street 2:SUITE 602
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203
Practice Address - Country:US
Practice Address - Phone:615-312-0600
Practice Address - Fax:615-320-3259
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL342382085R0202X
TN513002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04357014Medicaid
AL511-61752OtherBLUE CROSS BLUE SHIELD
TNQ006343Medicaid
AL172629Medicaid
MS04357014Medicaid
AL101I304629Medicare PIN