Healthcare Provider Details

I. General information

NPI: 1467801266
Provider Name (Legal Business Name): JACOB ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N 15TH ST 6TH FLOOR
PHILADELPHIA PA
19102-1101
US

IV. Provider business mailing address

245 N 15TH ST 6TH FLOOR
PHILADELPHIA PA
19102-1101
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-7000
  • Fax: 215-762-7765
Mailing address:
  • Phone: 215-762-7000
  • Fax: 215-762-7765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number211059
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: