Basic Information
| Provider Information | |||||||||
| NPI: | 1437313244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACIEJEWSKI | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 BRIGHAM DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198727700 | ||||||||
| FaxNumber: | 4198470196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 BRIGHAM DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198727700 | ||||||||
| FaxNumber: | 4198470196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35.093510 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2950230 | 05 | OH | MEDICAID | 05815 | 01 | PHC | OTHER | 000000625705 | 01 | OH | ANTHEM | OTHER | 9708368 | 01 | OH | AETNA | OTHER |