Provider Demographics
NPI:1942405246
Name:LAWRENCE M. JACOBY, M.D., PC
Entity Type:Organization
Organization Name:LAWRENCE M. JACOBY, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-673-1667
Mailing Address - Street 1:18 W AVON RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3583
Mailing Address - Country:US
Mailing Address - Phone:860-673-1667
Mailing Address - Fax:860-673-1544
Practice Address - Street 1:18 W AVON RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3583
Practice Address - Country:US
Practice Address - Phone:860-673-1667
Practice Address - Fax:860-673-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016756174400000X
CT022522174400000X
CT000178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010016756CT01OtherBCBS ANTHEM CONNECTICUT
CT18000OtherCONNECTICARE PA
CT731541OtherPHCS
CTP1595383OtherOXFORD
DE290000178CT01OtherBCBS ANTHEM CT -- PA
CT44259OtherAETNA
CT701896OtherCONNECTICARE DR.
DE290000178CT01OtherBCBS ANTHEM CT -- PA