1104888098 NPI number — LEWIS E JACOBSON MD

Table of content: LEWIS E JACOBSON MD (NPI 1104888098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104888098 NPI number — LEWIS E JACOBSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBSON
Provider First Name:
LEWIS
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104888098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11541 E WINCHESTER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLICOTT CITY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21042-2040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
833-220-2685
Provider Business Mailing Address Fax Number:
317-947-0839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8240 NAAB ROAD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-274-3086
Provider Business Practice Location Address Fax Number:
317-278-1886
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  1039371A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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