1871516963 NPI number — DR. ELIZABETH S JACOBS MD

Table of content: DR. ELIZABETH S JACOBS MD (NPI 1871516963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871516963 NPI number — DR. ELIZABETH S JACOBS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBS
Provider First Name:
ELIZABETH
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1871516963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9484
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02940-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-854-2500
Provider Business Mailing Address Fax Number:
401-854-2519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
593 EDDY ST
Provider Second Line Business Practice Location Address:
CLAVERICK 2
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-519-1604
Provider Business Practice Location Address Fax Number:
401-272-0538
Provider Enumeration Date:
07/26/2006

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: 2080P0204X , with the licence number:  MD12366 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09/13/2007 . This is a "NHPRI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 1871516 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1871516963 . This is a "NPI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 04/15/2009 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 12/29/2008 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2135001 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07/24/2007 . This is a "BCBS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 007059436 . This is a "RI MEDICARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 939025129 . This is a "RI MEDICARE GROUP NUMBER" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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