NPIMap

Individual provider Active NPI

Jordan M Wagner, PA

  • Family Medicine Physician
  • Niles, MI
National Provider Identifier
1831383074
Registry record updated Mar 14, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
5601005116 Issued in MI
Practice address
2002 S 11TH St
Niles, MI 49120-4074
Phone
(269) 687-0200
Fax
(269) 684-0199
NPI assigned
Aug 30, 2007
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 14, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 5601005116 MI Primary

Addresses

Primary practice location

2002 S 11TH St
Niles, MI 49120-4074

Mailing address

6416 Deans Hill Rd
Berrien Center, MI 49102-9750
Phone (269) 471-7741

Other identifiers 1

IdentifierTypeStateIssuer
1831383074MedicaidMI

Other names 1

  • Jordan M Frizzo Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20071023000303 MI Practitioner - Physician Assistant 2163518077 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2007
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Lakeland Community Hospital WatervlietGroup PAC ID 7416942750, 66 clinicians

Practice addresses (Care Compare)

2002 S 11TH St
Niles, MI 49120-4074
Phone (269) 687-0200

Hospital & facility affiliations

  • Lakeland Hospital, St Joseph Hospital, St Joseph, MI, CCN 230021
  • Corewell Health Watervliet Hospital Hospital, Watervliet, MI, CCN 230078

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
5601005116MIMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Lakeland Community Hospital Watervliet CurrentSince Nov 30, 2013 Accepting new patients
Lakeland Community Hospital Watervliet CurrentSince Nov 30, 2013 Accepting new patients
Genesis Family Health Center, PLC Family Medicine Past Accepting new patients
Lakeland Community Hospital Watervliet Family Medicine Past Accepting new patients

Locations

31 N Saint Joseph Ave
Niles, MI 49120
Phone (269) 428-2417

2002 S 11th St
Niles, MI 49120
Phone (269) 687-0200

400 Medical Park Dr
Watervliet, MI 49098
Phone (269) 463-3111

Interoperability endpoints

  • Direct secure messaging: jwagner1309@lakeland.midirect.net
  • Direct secure messaging: jwagner1272507@epic00.corewelldirect.org

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 2

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1188432000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1363219200000",
    "number": "1831383074",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6416 DEANS HILL RD",
            "city": "BERRIEN CENTER",
            "state": "MI",
            "postal_code": "491029750",
            "telephone_number": "269-471-7741",
            "fax_number": "269-471-1581"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2002 S 11TH ST",
            "city": "NILES",
            "state": "MI",
            "postal_code": "491204074",
            "telephone_number": "269-687-0200",
            "fax_number": "269-684-0199"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "JORDAN",
        "middle_name": "M",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-08-30",
        "last_updated": "2013-03-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "5601005116",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1831383074",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JORDAN",
            "last_name": "FRIZZO",
            "middle_name": "M",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Niles, MI

Sources for this page

Verify at the official NPI Registry.