Provider Demographics
NPI:1346214665
Name:JACOBSON, EDWARD L (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:GALEN MEDICAL GROUP
Mailing Address - City:CHATT
Mailing Address - State:TN
Mailing Address - Zip Code:37401
Mailing Address - Country:US
Mailing Address - Phone:423-894-3725
Mailing Address - Fax:423-954-9019
Practice Address - Street 1:961 SPRING CREEK RD
Practice Address - Street 2:GALEN MEDICAL GROUP
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412
Practice Address - Country:US
Practice Address - Phone:423-892-2221
Practice Address - Fax:423-490-3407
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN28164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3806302Medicaid
G61790Medicare UPIN
TN3806302Medicaid