Basic Information
| Provider Information | |||||||||
| NPI: | 1811954290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1850 W ARLINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278345704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527526101 | ||||||||
| FaxNumber: | 2527526600 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 E ARLINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278585872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523554357 | ||||||||
| FaxNumber: | 2523550827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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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 | 207Q00000X | 9500626 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8947189 | 05 | NC | MEDICAID |