Individual
MICHAEL D JACOB
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
7150 CLEARVISTA DRIVE, INDIANAPOLIS, IN 37043
(317) 621-5890
(317) 355-2205
Mailing address
6626 E 75TH ST, INDIANAPOLIS, IN 46250-2805
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
103360
TN
367500000X
Certified Registered Nurse Anesthetist
Primary
28181433A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000595410
ANTHEM
IN
05
—
200926510
—
IN
05
—
3628323
—
TN
Enumeration date
05/03/2006
Last updated
07/21/2015
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