=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669096111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB ALEXANDER MARTIN NOVACK DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2020
-----------------------------------------------------
Last Update Date | 10/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1037 WATER ST STE 1
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-967-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22644 RIDGEWAY ST
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48080-1476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-216-2615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 5101028607
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------