Healthcare Provider Details

I. General information

NPI: 1629364385
Provider Name (Legal Business Name): MARY MARGARET HOLLOMAN JORDAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 07/15/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PARK DR STE 430
CONCORD NC
28025-2982
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-7070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2016-01744
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: