Provider Demographics
NPI:1538115803
Name:JACOBY, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:5350 BECKLEY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-4178
Mailing Address - Country:US
Mailing Address - Phone:269-979-9400
Mailing Address - Fax:269-979-2091
Practice Address - Street 1:555 LINN ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1524
Practice Address - Country:US
Practice Address - Phone:616-235-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010426762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
310A710590OtherBCBS PIN
DD4837OtherMEDICARE RR PIN
MI4860092Medicaid
MI4860083Medicaid
MI4860083Medicaid
310A710590OtherBCBS PIN
MI4860092Medicaid