Provider Demographics
NPI:1508824905
Name:JACOB, MICHAEL D (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:JACOB
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7150 CLEARVISTA DRIVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:317-621-5890
Practice Address - Fax:317-355-2205
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN103360367500000X
IN28181433A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000595410OtherANTHEM
TN3628323Medicaid
IN200926510Medicaid
TN3628323Medicaid
IN262030CMedicare PIN