MEDICARE: MYRON H JACOBS 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	207RP1001X	Pulmonary Disease Physician	R3942	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110154795	OTHER	MO	RR MEDICARE PCI
2	29006738	OTHER	MO	RR MEDICARE PSC

Other Identifiers

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

General Provider Information

NPI Number	:	1255322731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRON H JACOBS M.D.

Provider Business Mailing Address
First Line	:	11133 DUNN RD
Second Line	:	SUITE 2335
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6119
Country	:	US
Telephone Number	:	314-653-5007
Fax Number	:	314-653-4149

Provider Business Practice Location Address
First Line	:	11133 DUNN RD
Second Line	:	SUITE 2335
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6119
Country	:	US
Telephone Number	:	314-653-5007
Fax Number	:	314-653-4149

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	11/05/2009

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Directions to “ MYRON H JACOBS M.D.” Practice Location

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