MEDICARE: ALI BEN-JACOB MD

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	207RH0003X	Hematology & Oncology Physician	292373-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1083611669	OTHER	UT	NATIONAL PROVIDER IDENTIFIER

General Provider Information

NPI Number	:	1083611669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALI BEN-JACOB MD

Provider Business Mailing Address
First Line	:	1281 NORTH 600 EAST
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2443
Country	:	US
Telephone Number	:	435-752-5999
Fax Number	:	435-752-5551

Provider Business Practice Location Address
First Line	:	1281 NORTH 600 EAST
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2443
Country	:	US
Telephone Number	:	435-752-5999
Fax Number	:	435-752-5551

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	11/03/2014

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