Provider Demographics
NPI:1437583630
Name:HARRY S. JACOB MD
Entity Type:Organization
Organization Name:HARRY S. JACOB MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-354-7900
Mailing Address - Street 1:2800 MARCUS AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1113
Mailing Address - Country:US
Mailing Address - Phone:516-354-7900
Mailing Address - Fax:516-354-7111
Practice Address - Street 1:2800 MARCUS AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1113
Practice Address - Country:US
Practice Address - Phone:516-354-7900
Practice Address - Fax:516-354-7111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-25
Last Update Date:2013-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112426261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care