Healthcare Provider Details

I. General information

NPI: 1033173562
Provider Name (Legal Business Name): EDMOND R JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 TIGER BLVD
CLEMSON SC
29631-1480
US

IV. Provider business mailing address

885 TIGER BLVD
CLEMSON SC
29631-1480
US

V. Phone/Fax

Practice location:
  • Phone: 864-654-6800
  • Fax: 864-654-7672
Mailing address:
  • Phone: 864-654-6800
  • Fax: 864-654-7672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11861
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: