Provider Demographics
NPI:1821017526
Name:JACOB, PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:JACOB
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 1:140 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-3102
Mailing Address - Country:US
Mailing Address - Phone:207-768-4315
Mailing Address - Fax:207-768-4390
Practice Address - Street 1:140 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3102
Practice Address - Country:US
Practice Address - Phone:207-768-4315
Practice Address - Fax:207-768-4390
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15057207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1821017526Medicaid
MEHX3309Medicare PIN