MEDICARE: ROBERT R. JACOBS D.O.

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	207P00000X	Emergency Medicine Physician	E-2641	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5L634	OTHER	AR	BCBS

General Provider Information

NPI Number	:	1558347286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT R. JACOBS D.O.

Provider Business Mailing Address
First Line	:	778 SCOGIN DR
Second Line	:
City	:	MONTICELLO
State	:	AR
Zip	:	71655-5729
Country	:	US
Telephone Number	:	870-367-2411
Fax Number	:	870-460-3562

Provider Business Practice Location Address
First Line	:	700 W GROVE ST
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4416
Country	:	US
Telephone Number	:	870-863-2200
Fax Number	:	870-864-0202

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

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	07/08/2007

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