Provider Demographics
NPI:1831162494
Name:JACOB, NADUVATHUSERY
Entity type:Individual
Prefix:
First Name:NADUVATHUSERY
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:N.J.
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:WESTERN PSYCHIATRIC HOSPITAL
Mailing Address - Street 2:3811 O HARA ST
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:WESTERN PSYCHIATRIC HOSPITAL
Practice Address - Street 2:3811 O HARA ST
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213
Practice Address - Country:US
Practice Address - Phone:412-246-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55272174400000X
PAMD045805L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001298825Medicaid
PA121980F3FMedicare ID - Type Unspecified
PA001298825Medicaid