Basic Information
Provider Information | |||||||||
NPI: | 1942255328 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBS | ||||||||
FirstName: | ELI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3735 NAZARETH RD | ||||||||
Address2: | SUITE 206 | ||||||||
City: | EASTON | ||||||||
State: | PA | ||||||||
PostalCode: | 180458338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6102526243 | ||||||||
FaxNumber: | 6102528614 | ||||||||
Practice Location | |||||||||
Address1: | 3735 NAZARETH RD | ||||||||
Address2: | SUITE 206 | ||||||||
City: | EASTON | ||||||||
State: | PA | ||||||||
PostalCode: | 180458338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6102526243 | ||||||||
FaxNumber: | 6102528614 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 12/23/2010 | ||||||||
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 | 2085N0904X | OS004065L | PA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
ID Information
ID | Type | State | Issuer | Description | 00857876 | 05 | PA |   | MEDICAID |