MEDICARE: EDUARDO JACOBS

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	208D00000X	General Practice Physician	4301097822	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	802322652	OTHER	MI	LARA

General Provider Information

NPI Number	:	1518517028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDUARDO JACOBS

Provider Business Mailing Address
First Line	:	PO BOX 1465
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48090-1465
Country	:	US
Telephone Number	:	586-557-4441
Fax Number	:

Provider Business Practice Location Address
First Line	:	42301 MOUND RD
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314-3148
Country	:	US
Telephone Number	:	586-557-4441
Fax Number	:

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

Provider Enumeration Date	:	09/17/2019
Last Update Date	:	09/17/2019

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