Provider Demographics
NPI:1629074190
Name:JACOBSON, PAUL ANDERS (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANDERS
Last Name:JACOBSON
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 1:701 W FRONT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2236
Mailing Address - Country:US
Mailing Address - Phone:231-935-0800
Mailing Address - Fax:231-935-0808
Practice Address - Street 1:701 W FRONT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2236
Practice Address - Country:US
Practice Address - Phone:231-935-0800
Practice Address - Fax:231-935-0808
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076134207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4212842Medicaid
MI0B81023OtherBCBSM
N13430002Medicare PIN
MI0B81023OtherBCBSM