Healthcare Provider Details

I. General information

NPI: 1174095640
Provider Name (Legal Business Name): ANTHONY L. JORDAN HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 LAKE AVE
ROCHESTER NY
14608-1208
US

IV. Provider business mailing address

214C LAKE AVE
ROCHESTER NY
14608-1208
US

V. Phone/Fax

Practice location:
  • Phone: 585-423-5800
  • Fax: 585-784-5981
Mailing address:
  • Phone: 585-423-2816
  • Fax: 585-423-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MONICA M. GRAHAM
Title or Position: BILLING MANGER
Credential: CMBS, CMC
Phone: 585-423-2821