Provider Demographics
NPI:1740367416
Name:EUGENE E JACOB MD PLLC
Entity type:Organization
Organization Name:EUGENE E JACOB MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-222-0598
Mailing Address - Street 1:1023 NEW MOODY LN
Mailing Address - Street 2:STE 102
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9177
Mailing Address - Country:US
Mailing Address - Phone:502-222-0598
Mailing Address - Fax:502-222-7446
Practice Address - Street 1:1023 NEW MOODY LN
Practice Address - Street 2:STE 102
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9177
Practice Address - Country:US
Practice Address - Phone:502-222-0598
Practice Address - Fax:502-222-7446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23227207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC69123Medicare UPIN