MEDICARE: JORDAN HOSPITAL ANESTHESIA ASSOCIATES, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician		MA
2	207L00000X	Anesthesiology Physician		MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1447203500	OTHER	MA	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447203500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JORDAN HOSPITAL ANESTHESIA ASSOCIATES, PC

Provider Business Mailing Address
First Line	:	68 N MAIN ST
Second Line	:
City	:	CARVER
State	:	MA
Zip	:	02330-1128
Country	:	US
Telephone Number	:	508-747-7246
Fax Number	:	508-747-7256

Provider Business Practice Location Address
First Line	:	68 N MAIN ST
Second Line	:
City	:	CARVER
State	:	MA
Zip	:	02330-1128
Country	:	US
Telephone Number	:	508-747-7246
Fax Number	:	508-747-7256

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID GANNON
Credential	:	MD
Telephone Number	:	508-747-7246

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	04/24/2024

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