MEDICARE: QUINCY JORDAN MD LLC

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	033367	GA

General Provider Information

NPI Number	:	1972851384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUINCY JORDAN MD LLC

Provider Business Mailing Address
First Line	:	PO BOX 2105
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-2105
Country	:	US
Telephone Number	:	877-610-2791
Fax Number	:

Provider Business Practice Location Address
First Line	:	2350 SOUTH HOUSTON LAKE RD
Second Line	:	#902
City	:	KATHLEEN
State	:	GA
Zip	:	31047-5414
Country	:	US
Telephone Number	:	877-610-2791
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. QUINCY J JORDAN
Credential	:	MD
Telephone Number	:	877-610-2791

Provider Enumeration Date	:	08/16/2012
Last Update Date	:	09/04/2012

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