1669459962 NPI number — RICHARD P JACOBY DPM, PC

Table of content: (NPI 1669459962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669459962 NPI number — RICHARD P JACOBY DPM, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD P JACOBY DPM, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EXTREMITY HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1669459962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4747 N SCOTTSDALE RD STE C4005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85251-7666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-994-5977
Provider Business Mailing Address Fax Number:
480-672-2288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9475 E IRONWOOD SQUARE DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85258-4576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-994-5977
Provider Business Practice Location Address Fax Number:
480-990-9397
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBY
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-994-5977

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  00084 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2572688 . This is a "AETNA PIN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 700626 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA8041 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 189007100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0190960 . This is a "BCBSAZ PIN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1Z1219 . This is a "HEALTHNET PIN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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