MEDICARE: JACOB GATES M.D

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	4301509683	MI

General Provider Information

NPI Number	:	1205463866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB GATES M.D

Provider Business Mailing Address
First Line	:	24 FRANK LLOYD WHITE DRIVE
Second Line	:	SUITE J2000
City	:	ANN ARBOR
State	:	MI
Zip	:	48105
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 S CANTON CENTER RD
Second Line	:	SUITE 200
City	:	CANTON
State	:	MI
Zip	:	48188-6276
Country	:	US
Telephone Number	:	734-398-7880
Fax Number	:	734-761-7318

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

Provider Enumeration Date	:	03/24/2020
Last Update Date	:	07/03/2023

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