Basic Information
Provider Information | |||||||||
NPI: | 1104852201 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JORDAN | ||||||||
FirstName: | JULIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHOI | ||||||||
OtherFirstName: | JULIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2900 CHANCELLOR DR | ||||||||
Address2: |   | ||||||||
City: | CRESTVIEW HILLS | ||||||||
State: | KY | ||||||||
PostalCode: | 410175427 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593410288 | ||||||||
FaxNumber: | 8593632140 | ||||||||
Practice Location | |||||||||
Address1: | 2900 CHANCELLOR DR | ||||||||
Address2: |   | ||||||||
City: | CRESTVIEW HILLS | ||||||||
State: | KY | ||||||||
PostalCode: | 410175427 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593410288 | ||||||||
FaxNumber: | 8593632140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 03/18/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 38969 | KY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 174400000X | 38969 | KY | N |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 310674100 | 01 |   | FEDERAL BLACK LUNG | OTHER | 310674100 | 01 |   | US DEPT OF LABOR | OTHER | 64100241 | 05 | KY |   | MEDICAID | 7000160 | 01 |   | AETNA | OTHER | 000000360586 | 01 |   | ANTHEM | OTHER | 610677107043 | 01 | OH | CARESOURCE | OTHER |