MEDICARE: JOHN P 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	2085R0001X	Radiation Oncology Physician	01045864	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000588411	OTHER	IN	ANTHEM PIN
2	1487680518	OTHER	IN	GROUP NPI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568454163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN P JACOBS M.D.

Provider Business Mailing Address
First Line	:	225 E NORTH ST APT 505
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-1334
Country	:	US
Telephone Number	:	317-955-9747
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 CHESTER BLVD
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-1908
Country	:	US
Telephone Number	:	765-983-3168
Fax Number	:	765-983-3275

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

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	12/22/2008

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