Healthcare Provider Details

I. General information

NPI: 1336118363
Provider Name (Legal Business Name): MATTHIAS JOSEPH JORDAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W 3RD ST SUITE 100
MONTICELLO MN
55362-8791
US

IV. Provider business mailing address

7266 COUNTY ROAD 37 NE
SAINT MICHAEL MN
55376-3007
US

V. Phone/Fax

Practice location:
  • Phone: 763-295-8826
  • Fax: 763-295-1900
Mailing address:
  • Phone: 763-295-4789
  • Fax: 763-295-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25273
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: