Basic Information
| Provider Information | |||||||||
| NPI: | 1356506455 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROBERT W. JORDAN MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 RENAISSANCE TOWNE DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012957200 | ||||||||
| FaxNumber: | 8012954930 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 RENAISSANCE TOWNE DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012957200 | ||||||||
| FaxNumber: | 8012954930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8012957200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 166068-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.