Provider Demographics
NPI:1023054442
Name:ALLAN JACOBS MD PD
Entity type:Organization
Organization Name:ALLAN JACOBS MD PD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-265-1721
Mailing Address - Street 1:70 MARKET ST
Mailing Address - Street 2:SUITE #4
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1896
Mailing Address - Country:US
Mailing Address - Phone:315-265-1721
Mailing Address - Fax:315-265-0157
Practice Address - Street 1:70 MARKET ST
Practice Address - Street 2:SUITE #4
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1896
Practice Address - Country:US
Practice Address - Phone:315-265-1721
Practice Address - Fax:315-265-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02588425Medicaid
NY02588425Medicaid