Basic Information
| Provider Information | |||||||||
| NPI: | 1861851651 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JORDAN PHYSICIAN ASSOCIATES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BIDH-PLYMOUTH ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087462000 | ||||||||
| FaxNumber: | 5088301131 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087462000 | ||||||||
| FaxNumber: | 5088301131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2016 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREY | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5088302401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JORDAN PHYSICIAN ASSOCIATES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 110072193V | 05 | MA | MEDICAID |