=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518073915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB TRACHTENBERG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 01/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 559 W GERMANTOWN PIKE
-----------------------------------------------------
City | NORRISTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19403-4250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-622-1695
-----------------------------------------------------
Fax | 484-622-4259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 478
-----------------------------------------------------
City | VILLANOVA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19085-0478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-527-0511
-----------------------------------------------------
Fax | 610-270-2308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0805X
-----------------------------------------------------
Taxonomy Name | Geriatric Psychiatry Physician
-----------------------------------------------------
License Number | MD014012E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD014012E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------