MEDICARE: MR. COSMO GORDON JACOBS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	D21328	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093798639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. COSMO GORDON JACOBS MD

Provider Business Mailing Address
First Line	:	4001 LIBERTY HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-7545
Country	:	US
Telephone Number	:	410-578-1100
Fax Number	:	410-578-0596

Provider Business Practice Location Address
First Line	:	4001 LIBERTY HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-8053
Country	:	US
Telephone Number	:	410-578-1100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	10/04/2010

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