Healthcare Provider Details

I. General information

NPI: 1023646221
Provider Name (Legal Business Name): TAYLOR BLAINE JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 MISSOURI AVE
JEFFERSONVILLE IN
47130-3725
US

IV. Provider business mailing address

634 E BURNETT AVE
LOUISVILLE KY
40217-1122
US

V. Phone/Fax

Practice location:
  • Phone: 256-558-1836
  • Fax:
Mailing address:
  • Phone: 256-558-1836
  • Fax: 502-852-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1090432A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: