MEDICARE: DR. SALLY C JORDAN M.D.

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	174400000X	Specialist	154001-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1540011	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1497831424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALLY C JORDAN M.D.

Provider Business Mailing Address
First Line	:	955 YONKERS AVENUE
Second Line	:	BOX 21
City	:	YONKERS
State	:	NY
Zip	:	10704
Country	:	US
Telephone Number	:	914-472-5140
Fax Number	:	914-472-5270

Provider Business Practice Location Address
First Line	:	955 YONKERS AVE STE 100
Second Line	:
City	:	YONKERS
State	:	NY
Zip	:	10704-3062
Country	:	US
Telephone Number	:	914-472-5140
Fax Number	:	914-473-5270

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	10/22/2018

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