Provider Demographics
NPI:1144376617
Name:CHARLES A JACOBSON MD
Entity Type:Organization
Organization Name:CHARLES A JACOBSON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-883-2828
Mailing Address - Street 1:2500 W A ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-6000
Mailing Address - Country:US
Mailing Address - Phone:208-883-2828
Mailing Address - Fax:208-882-2179
Practice Address - Street 1:2500 W A ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-883-2828
Practice Address - Fax:208-882-2179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6567207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA319300000Medicare PIN
A89835Medicare UPIN