Provider Demographics
NPI:1477587780
Name:JACOB, MIRIAM SARA (MD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:SARA
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:J3-4
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-4036
Mailing Address - Fax:216-445-6192
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:J3-4
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-4036
Practice Address - Fax:216-445-6192
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.121506207RC0000X
MDD72731207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS062-0435OtherCAREFIRST BC/BS - REGIONAL
MD440701600Medicaid
MD974679-01OtherCAREFIRST BC/BS
MD223740Y3WMedicare PIN
MD974679-01OtherCAREFIRST BC/BS
I59030Medicare UPIN