Provider Demographics
NPI:1093903395
Name:JACOB WARD MD, LLC
Entity Type:Organization
Organization Name:JACOB WARD MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:T
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-592-4350
Mailing Address - Street 1:1200 BUCKHEAD XING STE B
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4259
Mailing Address - Country:US
Mailing Address - Phone:770-592-4350
Mailing Address - Fax:770-874-0028
Practice Address - Street 1:1200 BUCKHEAD XING STE B
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-4259
Practice Address - Country:US
Practice Address - Phone:770-592-4350
Practice Address - Fax:770-874-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6018Medicare PIN