=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568469658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD MATHEW JORDAN PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32071 BEAVER RUN DR STE B
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21804-1773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-341-6520
-----------------------------------------------------
Fax | 410-341-6526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1859
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21802-1859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-341-6520
-----------------------------------------------------
Fax | 410-341-6526
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 19052
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------