Basic Information
| Provider Information | |||||||||
| NPI: | 1386932473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JJO ANESTHESIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1847 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852991847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805072961 | ||||||||
| FaxNumber: | 4805072971 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 W FRYE RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807283000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2011 | ||||||||
| LastUpdateDate: | 07/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4805072961 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 41545 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | DS5506 | 01 | AZ | MEDICARE RR | OTHER | 625095 | 05 | AZ | MEDICAID | FJ1258703 | 01 | DEA | OTHER |