Basic Information
| Provider Information | |||||||||
| NPI: | 1316118763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT W JACEY MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2821 N PARHAM ROAD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232944412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047476966 | ||||||||
| FaxNumber: | 8043469390 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 N PARHAM ROAD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232944412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047476966 | ||||||||
| FaxNumber: | 8043469390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 05/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | RAY | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | STUART | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8047476966 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 0101024617 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 006380069 | 05 | VA | MEDICAID | C03829 | 01 | VA | MEDICARE GROUP | OTHER |