Basic Information
| Provider Information | |||||||||
| NPI: | 1134157597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 AIRPARK CENTER DR | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372175200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3918 MONTCLAIR RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MOUNTAIN BRK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352132425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057053550 | ||||||||
| FaxNumber: | 2057053554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | ME100342 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | MD.201843 | LA | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 2008-00217 | NC | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 0101245015 | VA | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 25031 | AL | Y | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | DR0050087 | CO | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 21330 | MS | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 25MA08863300 | NJ | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | N2577 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | E6005 | AR | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | MD31313 | SC | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | A110841 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 42796 | TN | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 060107 | GA | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 51136288 | 01 | AL | BLUE CROSS | OTHER |