Provider Demographics
NPI:1841210457
Name:JACOBSON MEDICAL SERVICES SC
Entity Type:Organization
Organization Name:JACOBSON MEDICAL SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-421-1226
Mailing Address - Street 1:1413 W. LEXINGTON
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4013
Mailing Address - Country:US
Mailing Address - Phone:312-421-1226
Mailing Address - Fax:312-421-1133
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-8000
Practice Address - Fax:312-421-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-618125174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
210258Medicare PIN