Provider Demographics
NPI:1053561449
Name:JACOBSON, MARK EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:30575 WOODWARD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0986
Mailing Address - Country:US
Mailing Address - Phone:248-280-8550
Mailing Address - Fax:248-280-8571
Practice Address - Street 1:30575 WOODWARD AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0986
Practice Address - Country:US
Practice Address - Phone:248-280-8550
Practice Address - Fax:248-280-8571
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.014767207X00000X
MI4301105117207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0888470001Medicare NSC
MIG06055023Medicare PIN