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General NPI Number Information
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NPI Number | 1396188025
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Entity Type | Individual
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Provider Name | JORDAN KENNETH MARSHALL MD
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Gender | Male
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Dates
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Enumeration Date | 04/11/2013
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Last Update Date | 12/18/2023
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Provider Practice Location Address
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Address Line | 2001 STATE ST
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62205-1803
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Country | US
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Telephone | 618-271-0204
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Fax |
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Provider Business Mailing Address
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Address Line | 7383 HAZEL AVE
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City | MAPLEWOOD
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State | MO
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Zip | 63143-3223
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Country | US
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Telephone | 907-482-3613
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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 | 2083A0100X
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Taxonomy Name | Aerospace Medicine Physician
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License Number | 0101257159
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 0101257159
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 036160684
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License Number State | IL
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