Healthcare Provider Details

I. General information

NPI: 1336344324
Provider Name (Legal Business Name): SUSAN STEWART JORDAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 NEWNAN CROSSING BLVD E STE 100
NEWNAN GA
30265-2551
US

IV. Provider business mailing address

900 CIRCLE 75 PKWY SE SUITE 1700
ATLANTA GA
30339-3035
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-4747
  • Fax: 678-673-5102
Mailing address:
  • Phone: 770-953-6929
  • Fax: 770-953-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number066169
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number066169
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: