Basic Information
| Provider Information | |||||||||
| NPI: | 1649295866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IACOBELLI | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | POMEROY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993479705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098431591 | ||||||||
| FaxNumber: | 5098431234 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 PATAHA ST | ||||||||
| Address2: | |||||||||
| City: | POMEROY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993478634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098431491 | ||||||||
| FaxNumber: | 5098431740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301074411 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M-12956 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4775269 | 05 | MI | MEDICAID | 0802506201 | 01 | MI | BCBSM INDIVIDUAL PIN | OTHER |