Healthcare Provider Details

I. General information

NPI: 1992367056
Provider Name (Legal Business Name): JORDAN HYDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 02/01/2025
Certification Date: 02/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 CHESTNUT ST STE 740
PHILADELPHIA PA
19107-4409
US

IV. Provider business mailing address

760 WOOD STREAM XING
VALPARAISO IN
46385-2972
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6680
  • Fax:
Mailing address:
  • Phone: 219-973-9790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD486362
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: