MEDICARE: DR. NINA T JORDANIA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	036107234	IL
2	2084P0800X	Psychiatry Physician	ME126750	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00924097	OTHER		MEDICARE RAILROAD (PROVIDER)
6	CA4748	OTHER		MEDICARE RAILROAD (GROUP)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036107234	OTHER	IL	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1033149844	OTHER	IL	CDPG NPI
5	0222075	OTHER	IL	BLUE CROSS GROUP
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164428074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NINA T JORDANIA MD

Provider Business Mailing Address
First Line	:	25111 PENNYROYAL DR
Second Line	:	STE 1
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7944
Country	:	US
Telephone Number	:	630-740-8375
Fax Number	:	630-740-8375

Provider Business Practice Location Address
First Line	:	6801 PORTO FINO CIR
Second Line	:	STE 1
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4344
Country	:	US
Telephone Number	:	239-225-0874
Fax Number	:	239-225-1465

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	03/20/2017

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Directions to “ DR. NINA T JORDANIA MD” Practice Location

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