Healthcare Provider Details

I. General information

NPI: 1174624415
Provider Name (Legal Business Name): JACOB STEPHEN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 GATEWAY DR
SYCAMORE IL
60178-3192
US

IV. Provider business mailing address

5 KISH HOSPITAL DR STE 103
DEKALB IL
60115-9602
US

V. Phone/Fax

Practice location:
  • Phone: 630-232-0280
  • Fax: 630-232-3895
Mailing address:
  • Phone: 630-232-0280
  • Fax: 630-232-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35.083380
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036133593
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: