Healthcare Provider Details

I. General information

NPI: 1508599754
Provider Name (Legal Business Name): JORDAN MICHAEL SWANBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3000
  • Fax:
Mailing address:
  • Phone: 217-588-2624
  • Fax: 217-757-7550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209025663
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: