Provider Demographics
NPI:1255322731
Name:JACOBS, MYRON H (MD)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:H
Last Name:JACOBS
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 1:11133 DUNN RD
Mailing Address - Street 2:SUITE 2335
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6119
Mailing Address - Country:US
Mailing Address - Phone:314-653-5007
Mailing Address - Fax:314-653-4149
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:SUITE 2335
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6119
Practice Address - Country:US
Practice Address - Phone:314-653-5007
Practice Address - Fax:314-653-4149
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3942207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110154795OtherRR MEDICARE PCI
MO29006738OtherRR MEDICARE PSC
MO200233203Medicaid
MO110154795OtherRR MEDICARE PCI
MO200233203Medicaid
A12682Medicare UPIN
MO002010417Medicare ID - Type UnspecifiedCPIN
MO29006738OtherRR MEDICARE PSC
MO000010902Medicare PIN