=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295724839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL J JORDAN DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2005
-----------------------------------------------------
Last Update Date | 10/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1399 JOHN B WHITE SR BLVD
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29306-3911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-595-9300
-----------------------------------------------------
Fax | 864-595-9400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1399 JOHN B WHITE SR BLVD
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29306-3911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-595-9300
-----------------------------------------------------
Fax | 864-595-9400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | 525
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | 525
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------