Provider Demographics
NPI:1033309380
Name:SCOTT, JACOB P (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:P
Last Name:SCOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6557
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-267-8244
Practice Address - Fax:616-267-7272
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN50966207R00000X
MI4301097324207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1033309380Medicaid
MNENROLLEDMedicaid
MNP00746352OtherMEDIICARE, RAILROAD
MN110012207Medicare PIN