Provider Demographics
NPI:1992786677
Name:JACOB, HANY J (MD)
Entity type:Individual
Prefix:
First Name:HANY
Middle Name:J
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HANY
Other - Middle Name:Y
Other - Last Name:KHALIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1661 HOLLAND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-4206
Mailing Address - Country:US
Mailing Address - Phone:419-794-1105
Mailing Address - Fax:419-794-1106
Practice Address - Street 1:1661 HOLLAND RD STE 100
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-4206
Practice Address - Country:US
Practice Address - Phone:419-794-1105
Practice Address - Fax:419-794-1106
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071855A207RC0200X, 207RP1001X
OH35-05-6351K207RP1001X
OH35056351207RS0012X
OH35-05-6351 K207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200823690Medicaid
OH290009694OtherMEDICARE RAILROAD
OH692684Medicaid
INP01202311OtherRR MEDICARE
OH0669806Medicare PIN
OH4060486Medicare PIN
OHE56170Medicare UPIN
INP01202311OtherRR MEDICARE
OH0669807Medicare PIN