MEDICARE: DR. JORDAN RUSSELL ROBERTS M.D.

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	207Q00000X	Family Medicine Physician	9897039-1205	UT

General Provider Information

NPI Number	:	1588043871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN RUSSELL ROBERTS M.D.

Provider Business Mailing Address
First Line	:	999 E MURRAY HOLLADAY RD STE 207
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-5093
Country	:	US
Telephone Number	:	801-268-2584
Fax Number	:	801-262-1168

Provider Business Practice Location Address
First Line	:	999 E MURRAY HOLLADAY RD STE 207
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-5093
Country	:	US
Telephone Number	:	801-268-2584
Fax Number	:	801-262-1168

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

Provider Enumeration Date	:	05/20/2015
Last Update Date	:	09/15/2018

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