MEDICARE: JORDAN MCINTOSH SIBOL PA-C

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	363A00000X	Physician Assistant	C0006624	MD

General Provider Information

NPI Number	:	1902329576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN MCINTOSH SIBOL PA-C

Provider Business Mailing Address
First Line	:	5000 COX RD
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-9263
Country	:	US
Telephone Number	:	804-968-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	2219 YORK RD STE 102
Second Line	:
City	:	TIMONIUM
State	:	MD
Zip	:	21093-3140
Country	:	US
Telephone Number	:	410-453-0002
Fax Number	:	410-453-0380

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

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	05/31/2023

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