Provider Demographics
NPI:1700117835
Name:JORDAN, PAUL ALAN
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ALAN
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:MISS
Other - First Name:PAUL
Other - Middle Name:ALAN
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:533 PELHAM RD
Mailing Address - Street 2:533 PELHAM ROAD
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-4002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:533 PELHAM RD
Practice Address - Street 2:533 PELHAM ROAD
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-4002
Practice Address - Country:US
Practice Address - Phone:215-713-4347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization