Healthcare Provider Details

I. General information

NPI: 1396188025
Provider Name (Legal Business Name): JORDAN KENNETH MARSHALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 STATE ST
EAST SAINT LOUIS IL
62205-1803
US

IV. Provider business mailing address

7383 HAZEL AVE
MAPLEWOOD MO
63143-3223
US

V. Phone/Fax

Practice location:
  • Phone: 618-271-0204
  • Fax:
Mailing address:
  • Phone: 907-482-3613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036160684
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0101257159
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101257159
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: