Provider Demographics
NPI:1144242587
Name:JACOB, ABRAHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:
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 1:200 OAK STREET SE, ROOM 270, MCNAMARA CENTER
Mailing Address - Street 2:MCNAMARA CENTER UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-2820
Mailing Address - Fax:612-624-0997
Practice Address - Street 1:516 DELAWARE STREET SE, PWB FOURTH FLOOR ROOM 4-100
Practice Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-672-7122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39348207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0591164Medicaid
WI34633600Medicaid
MN04-01462OtherMEDICA PRIMARY
MN04-07575OtherMEDICA CHOICE
MN721T5JAOtherBCBS - PCC
MN1016575OtherPREFERRED ONE
MN122189OtherUCARE
MNHP25847OtherHEALTHPARTNERS
MN792497OtherARAZ
MN04-08261OtherMEDICA CHOICE - PCC
MN349818200Medicaid
MN598T8JAOtherBCBS
MN598T8JAOtherBCBS
MN1016575OtherPREFERRED ONE
MN721T5JAOtherBCBS - PCC