Provider Demographics
NPI:1326088097
Name:HIGHLANDS PHYSICIAL MEDICINE AND REHABILITATION, PC
Entity Type:Organization
Organization Name:HIGHLANDS PHYSICIAL MEDICINE AND REHABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-619-3400
Mailing Address - Street 1:1175 58TH AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4807
Mailing Address - Country:US
Mailing Address - Phone:970-495-0300
Mailing Address - Fax:970-224-9624
Practice Address - Street 1:4100 UNION ST
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538
Practice Address - Country:US
Practice Address - Phone:970-619-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43793208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20238061Medicaid
COJA674614OtherANTHEM BCBS
DE7212OtherRAILROAD MEDICARE
COJA674614OtherANTHEM BCBS
CO20238061Medicaid