Provider Demographics
NPI:1063688497
Name:JACOB, MARK KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:KEVIN
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ALLEN ST
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4560
Mailing Address - Country:US
Mailing Address - Phone:913-909-7400
Mailing Address - Fax:
Practice Address - Street 1:300 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1014
Practice Address - Country:US
Practice Address - Phone:989-774-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086585207R00000X
IL036.161882207RC0200X
KS04-331614207RC0200X, 207RP1001X
NC2011-01117207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1653FOtherBCBSNC
NC5919082Medicaid
NC1653FOtherBCBSNC