Healthcare Provider Details

I. General information

NPI: 1215110697
Provider Name (Legal Business Name): CECIL BRYAN JORDAN II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2007
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 DUKES ST
SAINT GEORGE SC
29477-2501
US

IV. Provider business mailing address

109 DUKES ST
SAINT GEORGE SC
29477-2501
US

V. Phone/Fax

Practice location:
  • Phone: 843-563-2484
  • Fax:
Mailing address:
  • Phone: 843-563-2484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11810
License Number StateSC

VIII. Authorized Official

Name: CECIL BRYAN JORDAN II
Title or Position: OWNER
Credential: MD
Phone: 843-563-2484