Provider Demographics
NPI:1073567210
Name:JACOBS, MARIA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
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:PO BOX 824173
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 SAINT PAUL PL
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2001
Practice Address - Country:US
Practice Address - Phone:410-332-9055
Practice Address - Fax:410-576-5288
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00209382085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD321731100Medicaid
MDKDA7 / 617127-01OtherBC / BS OF MD
MDG010 / 0001OtherBLUECHOICE
MDG010 / 0001OtherBLUECHOICE
486M / F110Medicare ID - Type Unspecified