Basic Information
| Provider Information | |||||||||
| NPI: | 1811242753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALL | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
| FaxNumber: | 6164866702 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 S SULLIVAN AVE | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494121548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163913139 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101019819 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.