Healthcare Provider Details

I. General information

NPI: 1215198270
Provider Name (Legal Business Name): WILEY P JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 RICHLAND MEDICAL PARK DR DEPT OF EMERGENCY MEDICINE #350
COLUMBIA SC
29203-6863
US

IV. Provider business mailing address

5 RICHLAND MEDICAL PARK DR DEPT OF EMERGENCY MEDICINE #350
COLUMBIA SC
29203-6863
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-3790
  • Fax: 803-434-3946
Mailing address:
  • Phone: 803-434-3790
  • Fax: 803-434-3946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberLL30798
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: