Provider Demographics
NPI:1669646642
Name:HARVEY R. JACOBS
Entity Type:Organization
Organization Name:HARVEY R. JACOBS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-873-1111
Mailing Address - Street 1:25 CLYDE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5038
Mailing Address - Country:US
Mailing Address - Phone:732-873-1111
Mailing Address - Fax:
Practice Address - Street 1:25 CLYDE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5038
Practice Address - Country:US
Practice Address - Phone:732-873-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00105100261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1240307Medicaid
NJ134847Medicare PIN
NJ1240307Medicaid
NJT73087Medicare UPIN