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General NPI Number Information
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NPI Number | 1073142832
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Entity Type | Individual
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Provider Name | JORDAN ALEXANDER MADDOX DO
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Gender | Male
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Dates
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Enumeration Date | 04/03/2020
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Last Update Date | 01/15/2024
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Provider Practice Location Address
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Address Line | 259 E ERIE ST STE 2350
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City | CHICAGO
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State | IL
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Zip | 60611-3370
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Country | US
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Telephone | 312-926-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 4956 N WESTERN AVE APT 1S
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City | CHICAGO
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State | IL
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Zip | 60625-6884
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Country | US
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Telephone | 847-345-6688
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036.166417
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License Number State | IL
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