MEDICARE: ANNE USHA JACOB M.B.B.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	42911	MN
2	207Q00000X	Family Medicine Physician	2015008169	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033107636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNE USHA JACOB M.B.B.S.

Provider Business Mailing Address
First Line	:	3649 PAGE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-3807
Country	:	US
Telephone Number	:	314-288-0071
Fax Number	:	314-758-5210

Provider Business Practice Location Address
First Line	:	3649 PAGE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-3807
Country	:	US
Telephone Number	:	314-288-0071
Fax Number	:	314-758-5210

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	03/05/2021

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