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General NPI Number Information
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NPI Number | 1063688497
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Entity Type | Individual
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Provider Name | MARK KEVIN JACOB M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/06/2008
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Last Update Date | 12/27/2024
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Provider Practice Location Address
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Address Line | 1340 CHARLES ST STE 401
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City | ROCKFORD
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State | IL
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Zip | 61104-2200
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Country | US
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Telephone | 779-696-6102
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Fax |
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Provider Business Mailing Address
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Address Line | 160 ALLEN ST MEDICAL STAFF OFFICE
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City | RUTLAND
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State | VT
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Zip | 05701-4560
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Country | US
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Telephone | 913-909-7400
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301086585
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | 036.161882
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | 04-331614
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License Number State | KS
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Taxonomy #4
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 04-331614
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License Number State | KS
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Taxonomy #5
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 2011-01117
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License Number State | NC
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