Healthcare Provider Details

I. General information

NPI: 1669064077
Provider Name (Legal Business Name): SAMUEL DOUGLAS JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2021
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

3880 CONNECTICUT ST UNIT A
SAINT LOUIS MO
63116-4839
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-3000
  • Fax:
Mailing address:
  • Phone: 314-363-8997
  • Fax:

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025023828
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: