Basic Information
| Provider Information | |||||||||
| NPI: | 1467485607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3407 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477333407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124503405 | ||||||||
| FaxNumber: | 8124503099 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MARY ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124503405 | ||||||||
| FaxNumber: | 8124503099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 09/26/2014 | ||||||||
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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 | 207P00000X | 10648 | MT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 02003898A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 02993 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200844060 | 05 | IN | MEDICAID | 64127962 | 05 | KY | MEDICAID |