Basic Information
| Provider Information | |||||||||
| NPI: | 1669606992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 DODDS AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374043911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667305619 | ||||||||
| FaxNumber: | 4236983622 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 25TH AVE N | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153120600 | ||||||||
| FaxNumber: | 6153203259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 34238 | AL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 51300 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04357014 | 05 | MS | MEDICAID | 511-61752 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | Q006343 | 05 | TN | MEDICAID | 172629 | 05 | AL | MEDICAID |