Healthcare Provider Details

I. General information

NPI: 1043836844
Provider Name (Legal Business Name): JORDAN A MCMANUS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 SOUTH NEW BALLAS ROAD SUITE 2009 B
ST. LOUIS MO
63141
US

IV. Provider business mailing address

621 SOUTH NEW BALLAS ROAD SUITE 2009 B
ST. LOUIS MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6062
  • Fax: 314-251-4376
Mailing address:
  • Phone: 314-251-6062
  • Fax: 314-251-4376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2020017232
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: