Provider Demographics
NPI:1326020843
Name:JACOBSON, SAMUEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:S
Last Name:JACOBSON
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 1:975 E. THIRD STREET
Mailing Address - Street 2:ATTN: PAYER ENROLLMENT
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403
Mailing Address - Country:US
Mailing Address - Phone:423-778-9101
Mailing Address - Fax:423-778-9190
Practice Address - Street 1:975 E. THIRD STREET
Practice Address - Street 2:SUITE # C-735
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-778-9101
Practice Address - Fax:423-778-9190
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD52334207RP1001X
FLME0032787207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
D57175Medicare UPIN
D57175Medicare UPIN
61287ZMedicare ID - Type Unspecified