Basic Information
| Provider Information | |||||||||
| NPI: | 1932137981 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACOB REKEM MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7096 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099567725 | ||||||||
| FaxNumber: | 2099567733 | ||||||||
| Practice Location | |||||||||
| Address1: | 13100 STUDEBAKER ROAD | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628683751 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | REKEM | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5628683751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A403690 | 01 | CA | BLUE SHIELD OF CA | OTHER | 00A403690 | 05 | CA | MEDICAID |