Provider Demographics
NPI:1407856214
Name:JACOBS, NORMAN M (MD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:M
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 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-6942
Mailing Address - Fax:740-356-7851
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:SOMC
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662
Practice Address - Country:US
Practice Address - Phone:740-356-8117
Practice Address - Fax:740-353-1214
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350503022085N0700X, 2085R0202X
KY511072085R0202X
GUMC-1772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00176289OtherSOM RR MDCR PIN NUMBER
KY6478787200Medicaid
OH000000203530OtherBC/BS INDIVIDUAL PIN NO
KYTP318OtherKENTUCKY MEDICAL LICENSE
OH0635389Medicaid
OH0690175Medicare PIN
OH0635389Medicaid