Basic Information
| Provider Information | |||||||||
| NPI: | 1194263186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JORDAN PHYSICIAN ASSOCIATES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BIDH-PLYMOUTH PATHOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087462000 | ||||||||
| FaxNumber: | 5088301131 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088302466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2017 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREY | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5088302401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JORDAN PHYSICIAN ASSOCIATES, INC. | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 110072193Z | 05 | MA | MEDICAID |