Provider Demographics
NPI:1659369031
Name:THOMAS E. JACOB, D.P.M., P.C.
Entity Type:Organization
Organization Name:THOMAS E. JACOB, D.P.M., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LINGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-779-1160
Mailing Address - Street 1:23700 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1647
Mailing Address - Country:US
Mailing Address - Phone:586-779-1160
Mailing Address - Fax:586-779-1163
Practice Address - Street 1:23700 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1647
Practice Address - Country:US
Practice Address - Phone:586-779-1160
Practice Address - Fax:586-779-1163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI59010000499213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000002745OtherCAPE HEALTH PLAN
MI1014915-0001OtherWELLNESS PLAN
MI121471OtherCARE CHOICE HMO
MI0737520001OtherDME MEDICARE
MI101301OtherGREAT LAKES HEALTH PLAN
MI101301OtherGREAT LAKES HEALTH PLAN
MI121471OtherCARE CHOICE HMO