Provider Demographics
NPI:1992724553
Name:YOUNGERMAN, JORDAN S (MD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:S
Last Name:YOUNGERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:GSBLL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2857
Mailing Address - Fax:217-876-2874
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6303
Practice Address - Country:US
Practice Address - Phone:217-424-2442
Practice Address - Fax:217-424-9431
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084067174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208838Medicare PIN