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General NPI Number Information
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NPI Number | 1659369031
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Entity Type | Organization
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Legal Business Name | THOMAS E. JACOB, D.P.M., P.C.
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Dates
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Enumeration Date | 10/11/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 23700 GRATIOT AVE
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City | EASTPOINTE
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State | MI
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Zip | 48021-1647
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Country | US
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Telephone | 586-779-1160
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Fax | 586-779-1163
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Provider Business Mailing Address
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Address Line | 23700 GRATIOT AVE
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City | EASTPOINTE
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State | MI
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Zip | 48021-1647
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Country | US
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Telephone | 586-779-1160
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Fax | 586-779-1163
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. NANNETTE M. LINGEMAN
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Credential |
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Telephone | 586-779-1160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 59010000499
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License Number State | MI
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