Provider Demographics
NPI:1538575741
Name:WAYNE STATE UNIVERSITY-SCHOOL OF MEDICINE
Entity type:Organization
Organization Name:WAYNE STATE UNIVERSITY-SCHOOL OF MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSOR, OTOLARYNGOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-218-5557
Mailing Address - Street 1:4005, BOURRET AVE, APT 110
Mailing Address - Street 2:
Mailing Address - City:MONTREAL
Mailing Address - State:QUEBEC
Mailing Address - Zip Code:H3S1X1
Mailing Address - Country:CA
Mailing Address - Phone:514-515-8052
Mailing Address - Fax:
Practice Address - Street 1:4005, BOURRET AVE, APT 110
Practice Address - Street 2:
Practice Address - City:MONTREAL
Practice Address - State:QUEBEC
Practice Address - Zip Code:H3S1X1
Practice Address - Country:CA
Practice Address - Phone:514-515-8052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301106057281P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281P00000XHospitalsChronic Disease Hospital