=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801182662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN DOROMAL JACOB M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2011
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 834 WALNUT ST STE 650
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-6996
-----------------------------------------------------
Fax | 215-923-6003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1245 HIGHLAND AVE BLDG SUITE401
-----------------------------------------------------
City | ABINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19001-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-481-6070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD454429
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0102X
-----------------------------------------------------
Taxonomy Name | Surgical Critical Care Physician
-----------------------------------------------------
License Number | 308671
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2086S0102X
-----------------------------------------------------
Taxonomy Name | Surgical Critical Care Physician
-----------------------------------------------------
License Number | MD454429
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 308671
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | MD454429
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------