Basic Information
| Provider Information | |||||||||
| NPI: | 1730132556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | MINA | ||||||||
| MiddleName: | AYAD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D.,FACC,FSCAI | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 SPRING HILL AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366041416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514351200 | ||||||||
| FaxNumber: | 2514356357 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 SPRING HILL AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366041416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514351200 | ||||||||
| FaxNumber: | 2514356357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0002X | 31294 | AL | N | 207RC0000X | 31294 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 31294 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 2086S0129X | 31294 | AL | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000946844P | 05 | GA | MEDICAID | 000946844X | 05 | GA | MEDICAID | 000946844 | 05 | GA | MEDICAID | 000946844K | 05 | GA | MEDICAID | 000946844L | 05 | GA | MEDICAID | 000946844Q | 05 | GA | MEDICAID | 000946844R | 05 | GA | MEDICAID | 00946844A | 05 | GA | MEDICAID | 000946844O | 05 | GA | MEDICAID | 167695 | 05 | AL | MEDICAID |