Individual
DR. MARK KEVIN JACOB
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1340 CHARLES ST STE 401, ROCKFORD, IL 61104-2200
(779) 696-6102
Mailing address
160 ALLEN ST, MEDICAL STAFF OFFICE, RUTLAND, VT 05701-4560
(913) 909-7400
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
4301086585
MI
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
036.161882
IL
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
04-331614
KS
207RP1001X
Pulmonary Disease Physician
04-331614
KS
207RP1001X
Pulmonary Disease Physician
Primary
2011-01117
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1653F
BCBSNC
NC
05
—
5919082
—
NC
Enumeration date
05/06/2008
Last updated
12/27/2024
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