Basic Information
Provider Information | |||||||||
NPI: | 1720030349 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOB | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 843225 | ||||||||
Address2: |   | ||||||||
City: | KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641843225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7086331234 | ||||||||
FaxNumber: | 7083427100 | ||||||||
Practice Location | |||||||||
Address1: | 150 S MOUNT AUBURN RD | ||||||||
Address2: | STE 344 | ||||||||
City: | CAPE GIRARDEAU | ||||||||
State: | MO | ||||||||
PostalCode: | 637034910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733315515 | ||||||||
FaxNumber: | 5733315516 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 08/16/2010 | ||||||||
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 | 207VX0201X | 36615 | MO | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
ID | Type | State | Issuer | Description | 203568324 | 05 | MO |   | MEDICAID | 160306001 | 05 | AR |   | MEDICAID | P00262024 | 01 |   | RAILROAD MEDICARE | OTHER | 188833 | 01 |   | HEALTHLINK | OTHER | 444830 | 01 | MO | ANTHEM BCBS | OTHER |