Provider Demographics
NPI:1295875672
Name:RAUCHWERGER, JACOB JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JEFFREY
Last Name:RAUCHWERGER
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 1:36 LINCOLN AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5768
Mailing Address - Country:US
Mailing Address - Phone:516-417-8500
Mailing Address - Fax:516-208-8828
Practice Address - Street 1:36 LINCOLN AVE FL 1
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5768
Practice Address - Country:US
Practice Address - Phone:516-417-8500
Practice Address - Fax:516-208-8828
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046111208VP0014X, 207L00000X
NY229997208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02945586Medicaid
CT1295875672Medicaid
CT090000009Medicare UPIN
NYA400027369Medicare PIN