Provider Demographics
NPI:1508897273
Name:NORTH SHORE MEDICAL REHABILITATION, PC
Entity Type:Organization
Organization Name:NORTH SHORE MEDICAL REHABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAKOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-441-5700
Mailing Address - Street 1:8371 116TH ST
Mailing Address - Street 2:SUITE M2
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-3448
Mailing Address - Country:US
Mailing Address - Phone:718-441-5700
Mailing Address - Fax:718-441-5337
Practice Address - Street 1:8371 116TH ST
Practice Address - Street 2:SUITE M2
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-3448
Practice Address - Country:US
Practice Address - Phone:718-441-5700
Practice Address - Fax:718-441-5337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03577Medicare PIN