Provider Demographics
NPI:1518961531
Name:JACOBY, ROBERT G (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:JACOBY
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 1:2300 MIAMI VALLEY DR
Mailing Address - Street 2:STE 550
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-1298
Mailing Address - Country:US
Mailing Address - Phone:937-438-7500
Mailing Address - Fax:
Practice Address - Street 1:11091 ULYSSES STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434
Practice Address - Country:US
Practice Address - Phone:612-879-1000
Practice Address - Fax:612-879-0782
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2023-01262084N0400X
MN378072084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160230600Medicaid
F46005Medicare UPIN
MN130000610Medicare ID - Type Unspecified