Provider Demographics
NPI:1215913348
Name:JACOBSON, IRWIN (DO)
Entity type:Individual
Prefix:
First Name:IRWIN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-926-9010
Mailing Address - Fax:215-226-8286
Practice Address - Street 1:4000 N 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19140-2209
Practice Address - Country:US
Practice Address - Phone:215-229-7800
Practice Address - Fax:215-229-3693
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002250L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019190OtherAETNA HMO
PA3Y7795OtherHEALTH NET
PA30019058OtherKMHP
PAP00264978OtherRR MEDICARE
PA000658424Medicaid
PA1418OtherBRAVO HEALTH
PA0058370000OtherINDEPENDENCE BLUE CROSS
PA4088577OtherAETNA PPO
PA041665OtherHIGHMARK BLUE SHIELD
PA041665OtherHIGHMARK BLUE SHIELD
PA041665Medicare PIN