Provider Demographics
NPI:1417281411
Name:SUPERIOR PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:SUPERIOR PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-934-2600
Mailing Address - Street 1:324 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-1502
Mailing Address - Country:US
Mailing Address - Phone:906-934-2600
Mailing Address - Fax:
Practice Address - Street 1:324 5TH ST
Practice Address - Street 2:
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-1502
Practice Address - Country:US
Practice Address - Phone:906-934-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty