Basic Information
Provider Information | |||||||||
NPI: | 1609836162 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBS | ||||||||
FirstName: | SIMON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 TER HUEN DRIVE | ||||||||
Address2: | DEPARTMENT OF HOSPITAL MEDICINE | ||||||||
City: | FALMOUTH | ||||||||
State: | MA | ||||||||
PostalCode: | 025400000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 TER HEUN DR | ||||||||
Address2: | DEPARTMENT OF HOSPITAL MEDICINE | ||||||||
City: | FALMOUTH | ||||||||
State: | MA | ||||||||
PostalCode: | 025402503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5084573748 | ||||||||
FaxNumber: | 5084573749 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2006 | ||||||||
LastUpdateDate: | 06/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 237357 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 25MA079874 | NJ | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00214923 | 01 | MA | MEDICARE RAIL ROAD | OTHER | 0096741 | 05 | NJ |   | MEDICAID | P00342310 | 01 | NJ | RR MEDICARE | OTHER |