Provider Demographics
NPI:1699003194
Name:EMAD JACOB, MD PC
Entity type:Organization
Organization Name:EMAD JACOB, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-772-5211
Mailing Address - Street 1:714 KEARNY AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-3006
Mailing Address - Country:US
Mailing Address - Phone:201-772-5211
Mailing Address - Fax:201-428-1627
Practice Address - Street 1:714 KEARNY AVE
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-3006
Practice Address - Country:US
Practice Address - Phone:201-772-5211
Practice Address - Fax:201-428-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08462300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0179141Medicaid
NJ228497Medicare PIN
NJ139757Medicare PIN