Basic Information
Provider Information | |||||||||
NPI: | 1619915824 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBS | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | SOLOMON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M. D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1499 WALTON WAY STE 1400 | ||||||||
Address2: | ATTN: DONNA RAIFORD | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309012603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068288402 | ||||||||
FaxNumber: | 7067211793 | ||||||||
Practice Location | |||||||||
Address1: | 997 ST. SEBASTIAN WAY | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309012603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067216597 | ||||||||
FaxNumber: | 7067211793 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2006 | ||||||||
LastUpdateDate: | 12/16/2015 | ||||||||
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 | 207L00000X | 071681 | GA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LA0401X | 071681 | GA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine | 207LP2900X | 071681 | GA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 000291101C,D | 05 | GA |   | MEDICAID | 071681 | 01 | GA | GA LICENSES | OTHER | AJ2717291 | 01 | GA | DEA | OTHER |