Basic Information
| Provider Information | |||||||||
| NPI: | 1538145131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JORDAN PHYSICIAN ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 CORDAGE PARK CIR | ||||||||
| Address2: | SUITE 317 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023607331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088302428 | ||||||||
| FaxNumber: | 5088302502 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088302401 | ||||||||
| FaxNumber: | 5088301131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | COUGHLIN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5087462000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110072193A | 05 | MA | MEDICAID | M15987 | 01 | MA | BCBSMA | OTHER | AA229234 | 01 | MA | HARVARD PILGRIM HEALTHCARE | OTHER | 602198 | 01 | MA | TUFTS HEALTH PLAN | OTHER |