Healthcare Provider Details

I. General information

NPI: 1093219404
Provider Name (Legal Business Name): JORDAN KRISTOPHER ROMICK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1284
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1284
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-5480
  • Fax: 618-222-4792
Mailing address:
  • Phone: 618-233-5480
  • Fax: 618-222-4792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036162019
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036162019
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: