Provider Demographics
NPI:1790347243
Name:JACOB JACOBY MD
Entity Type:Organization
Organization Name:JACOB JACOBY MD
Other - Org Name:JACOB JACOBY MD PHD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:718-362-8184
Mailing Address - Street 1:612 CORPORATE WAY STE 2M
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2027
Mailing Address - Country:US
Mailing Address - Phone:718-362-8184
Mailing Address - Fax:718-362-1651
Practice Address - Street 1:100 ROUTE 59 STE 103
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4927
Practice Address - Country:US
Practice Address - Phone:718-362-8184
Practice Address - Fax:718-362-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02327411Medicaid