Basic Information
| Provider Information | |||||||||
| NPI: | 1932118296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | MANLEY | ||||||||
| MiddleName: | MCRAE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122309 | ||||||||
| Address2: | DEPT 2309 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942919 | ||||||||
| FaxNumber: | 3374943069 | ||||||||
| Practice Location | |||||||||
| Address1: | 2770 3RD AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942750 | ||||||||
| FaxNumber: | 3374942760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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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 | 207RP1001X | 017837 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | P00221352 | 01 | LA | RAILROAD MEDICARE | OTHER | 1468444 | 05 | LA | MEDICAID |