Provider Demographics
NPI:1316130701
Name:VINEYARD MEDICAL SERVICES PC
Entity type:Organization
Organization Name:VINEYARD MEDICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-639-4400
Mailing Address - Street 1:364 STATE RD
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568
Mailing Address - Country:US
Mailing Address - Phone:508-693-4400
Mailing Address - Fax:508-693-2098
Practice Address - Street 1:364 STATE RD
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568
Practice Address - Country:US
Practice Address - Phone:508-693-4400
Practice Address - Fax:508-693-2098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110091889AMedicaid
MA0003576Medicare PIN