Healthcare Provider Details

I. General information

NPI: 1801327812
Provider Name (Legal Business Name): PHILLIP JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR RALEIGH BUILDING, SUITE 304
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

6379 CENTER DR
NORFOLK VA
23502-4102
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-3397
  • Fax: 757-388-2885
Mailing address:
  • Phone: 757-388-3397
  • Fax: 757-388-2885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101269116
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: