Provider Demographics
NPI:1780690214
Name:MANN, JORDAN L (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:MANN
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 1:6450 RELIABLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686
Mailing Address - Country:US
Mailing Address - Phone:217-788-3000
Mailing Address - Fax:217-788-5577
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781
Practice Address - Country:US
Practice Address - Phone:217-788-3060
Practice Address - Fax:217-788-5577
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360692741Medicaid
C44887Medicare UPIN
IL0360692741Medicaid