Healthcare Provider Details

I. General information

NPI: 1528440724
Provider Name (Legal Business Name): JORDAN SESTAK BRUCE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDAN LEIGH BRUCE MD

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST STE 3100
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

201 E MADISON ST STE 328
SPRINGFIELD IL
62702-5131
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125066620
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036.150367
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number217843
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: