Healthcare Provider Details

I. General information

NPI: 1144212549
Provider Name (Legal Business Name): ANTHONY SCOTT JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12080 MCMILLAN RD
BOISE ID
83713-2462
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-4955
  • Fax: 208-375-5568
Mailing address:
  • Phone: 208-375-4955
  • Fax: 208-375-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01056364A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-9584
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: