Basic Information
| Provider Information | |||||||||
| NPI: | 1750415527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBY | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 PULASKI DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194062802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107685940 | ||||||||
| FaxNumber: | 6107685947 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 PULASKI DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194062802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107685940 | ||||||||
| FaxNumber: | 6107685947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 25MA08447300 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MD427065 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 25MA084473000 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | MD427065 | PA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2106499 | 01 | PA | PENNSYLVANIA BLUE SHIELD | OTHER | 3722652000 | 01 | PA | INDEPENDENCE BLUE CROSS - PERSONAL CHOICE | OTHER | 3722652000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER |