Dr Jacob S Form, DPM is a medicare enrolled "Podiatrist" provider in Lafayette Hill, Pennsylvania. His current practice location is
4129 Franklin Way, Lafayette Hill, Pennsylvania. You can reach out to his office (for appointments etc.) via phone at
(215) 292-2637.
Dr Jacob S Form is licensed to practice in Pennsylvania (license number SC002170L) and he also participates in the medicare program. He does not accept medicare assignments directly but he may accept medicare through third-party (refer to Reassignment section below) and may also prescribe medicare part D drugs. His NPI Number is 1356367494.
Healthcare Provider's Profile
| Full Name | Dr Jacob S Form |
|---|
| Gender | Male |
|---|
| Speciality | Podiatrist |
|---|
| Location | 4129 Franklin Way, Lafayette Hill, Pennsylvania |
|---|
| Accepts Medicare Assignments | Medicare enrolled and may accept medicare through third-party reassignment. May prescribe medicare part D drugs. |
|---|
NPI Data:
- NPI Number: 1356367494
- Provider Enumeration Date: 07/14/2006
- Last Update Date: 04/27/2012
Medicare PECOS Information:
- PECOS PAC ID: 7911909643
- Enrollment ID: I20070209000326
Medical Identifiers
Medical identifiers for Dr Jacob S Form such as npi, medicare ID, medicare PIN, medicaid, etc.
| Identifier | Type | State | Issuer |
|---|
| 1356367494 | NPI | - | NPPES |
| 000159517 | Other | PA | BLUE SHIELD |
| 0048261000 | Other | PA | BLUE CROSS HMO |
| 10766 | Other | PA | ELDER HEALTH |
| 0080982301 | Other | PA | AMERICHOICE |
| 33473 | Other | PA | HEALTH PARTNERS |
| 1000746 | Other | PA | KEYSTONE MERCY |
Medical Taxonomies and Licenses
| Taxonomy | Type | License (State) | Status |
|---|
| 213E00000X | Podiatrist | SC002170L (Pennsylvania) | Primary |
Medicare Reassignments
Some practitioners may not bill the customers directly but medicare billing happens through clinics / group practice / hospitals where the provider works. Medicare reassignment of benefits is a mechanism by which practitioners allow third parties to bill and receive payment for medicare services performed by them. Dr Jacob S Form allows following entities to bill medicare on his behalf.
| Provider Name | Lifecare Podiatry, P.c. |
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| Provider Type | Part B Supplier - Clinic/group Practice |
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| Provider Identifiers | NPI Number: 1134175193
PECOS PAC ID: 1951290279
Enrollment ID: O20040315000187 |
|---|
Medicare Part D Prescriber Enrollment
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. Dr Jacob S Form is
enrolled with medicare and thus, if eligible, can prescribe medicare part D drugs to patients with medicare part D benefits.
Mailing Address and Practice Location
| Mailing Address | Practice Location Address |
|---|
Dr Jacob S Form, DPM
4129 Franklin Way,
Lafayette Hill, PA 19444-1300
Ph: (215) 292-2637 | Dr Jacob S Form, DPM
4129 Franklin Way,
Lafayette Hill, PA 19444-1300
Ph: (215) 292-2637 |
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