Provider Demographics
NPI:1932423696
Name:JACOB, EDMUND DOROMAL (MD)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:DOROMAL
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD # 417
Mailing Address - Street 2:DIVISION OF HOSPITAL MEDICINE
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-8144
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD # 417
Practice Address - Street 2:DIVISION OF HOSPITAL MEDICINE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-8144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301099385207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program