Provider Demographics
NPI:1255866372
Name:JACOBS RADIOLOGY PLLC
Entity Type:Organization
Organization Name:JACOBS RADIOLOGY PLLC
Other - Org Name:SOUTH SHORE VEIN AND IMAGE-GUIDED MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-865-1234
Mailing Address - Street 1:24 MAPLE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4259
Mailing Address - Country:US
Mailing Address - Phone:516-865-1234
Mailing Address - Fax:
Practice Address - Street 1:24 MAPLE AVE STE 2
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4259
Practice Address - Country:US
Practice Address - Phone:516-865-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
202K00000X
NY257302-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty