Basic Information
| Provider Information | |||||||||
| NPI: | 1902915135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | COLLIER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 2428 KNOB CREEK RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232825054 | ||||||||
| FaxNumber: | 4232830516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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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 | 207RC0000X | 11556 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 320315 | 01 | VA | ANTHEM | OTHER | 4017303 | 01 | TN | BCBS | OTHER | 89014AT | 05 | NC | MEDICAID | 890564P | 05 | NC | MEDICAID | 3373123 | 05 | TN | MEDICAID | 005867975 | 05 | VA | MEDICAID | TN0103 | 01 | TN | JDH | OTHER |