Provider Demographics
NPI:1548624935
Name:SIU, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SIU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ORNAC
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 OLD ROAD TO 9 ACRE COR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4169
Practice Address - Country:US
Practice Address - Phone:586-263-2972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151010109207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine