Basic Information
Provider Information | |||||||||
NPI: | 1811911993 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBY | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 403 W HIGHLAND BLVD | ||||||||
Address2: |   | ||||||||
City: | INVERNESS | ||||||||
State: | FL | ||||||||
PostalCode: | 344524717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527263646 | ||||||||
FaxNumber: | 3527260079 | ||||||||
Practice Location | |||||||||
Address1: | 403 W HIGHLAND BLVD | ||||||||
Address2: |   | ||||||||
City: | INVERNESS | ||||||||
State: | FL | ||||||||
PostalCode: | 344524717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527263646 | ||||||||
FaxNumber: | 3527260079 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2006 | ||||||||
LastUpdateDate: | 04/03/2017 | ||||||||
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 | 208600000X | 036046008 | IL | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 54194-20 | WI | Y |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | ME105854 | FL | N |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 04929950 | 01 | IL | BC BS | OTHER | 036046008 | 05 | IL |   | MEDICAID |