Provider Demographics
NPI:1003246828
Name:JACOB GENERAL SURGERY, LLC
Entity Type:Organization
Organization Name:JACOB GENERAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-264-9353
Mailing Address - Street 1:4228 HOUMA BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-3000
Mailing Address - Country:US
Mailing Address - Phone:504-264-9353
Mailing Address - Fax:504-301-9312
Practice Address - Street 1:4228 HOUMA BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3000
Practice Address - Country:US
Practice Address - Phone:504-264-9353
Practice Address - Fax:504-301-9312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201551208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508535Medicaid