Basic Information
| Provider Information | |||||||||
| NPI: | 1518947456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | LANG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702972200 | ||||||||
| FaxNumber: | 7705348139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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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 | 207VG0400X | 057204 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | 057204 | GA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 238806338A | 05 | GA | MEDICAID | 4346566 | 01 | GA | CIGNA | OTHER | 238806338C | 05 | GA | MEDICAID | 238806338D | 05 | GA | MEDICAID | 0677272 | 01 | GA | UNITED HEALTHCARE | OTHER | 238806338E | 05 | GA | MEDICAID | 52197850 | 01 | GA | BCBS | OTHER | 10038639 | 01 | GA | AMERIGROUP | OTHER | 340853 | 01 | GA | WELLCARE | OTHER | 238806338B | 05 | GA | MEDICAID | 4069685 | 01 | GA | AETNA | OTHER |