Provider Demographics
NPI:1760455869
Name:KALO, JACOB (MD, PC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:KALO
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28477 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5438
Mailing Address - Country:US
Mailing Address - Phone:586-751-7070
Mailing Address - Fax:586-751-7071
Practice Address - Street 1:15650 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1444
Practice Address - Country:US
Practice Address - Phone:313-526-3600
Practice Address - Fax:313-526-3603
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040053174400000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0500428OtherBLUE CROSS ID
MI1594887Medicaid
MI38 2343250OtherTAX ID NUMBER
MI38 2343250OtherTAX ID NUMBER
MIA77145Medicare UPIN