Jacob S. Form, D.P.M.

Primary specialty

PodiatristTaxonomy code 213E00000X

License

SC002170L Issued in PA

Practice address

4129 Franklin Way
Lafayette Hill, PA 19444-1300

Phone

(215) 292-2637

NPI assigned

Jul 14, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 6

Medicare fee-for-service enrollment

Enrolled in PA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Podiatry

Education

Temple University School of Podiatric Medicine, 1980

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Merit-based Incentive Payment System (MIPS)

Final score

94.08 of 100Reported as group

Quality

73.79

Promoting interoperability

95

Improvement activities

40

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/12226/brand/1/csg/1/fhir/r4
• Direct secure messaging: jacob.form.1@12226.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Lifecare Podiatry, P.C.

  • Podiatrist
  • Wayne, PA
  • NPI 1134175193
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152835200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1335484800000",
    "number": "1356367494",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4129 FRANKLIN WAY",
            "city": "LAFAYETTE HILL",
            "state": "PA",
            "postal_code": "194441300",
            "telephone_number": "215-292-2637"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4129 FRANKLIN WAY",
            "city": "LAFAYETTE HILL",
            "state": "PA",
            "postal_code": "194441300",
            "telephone_number": "215-292-2637"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FORM",
        "first_name": "JACOB",
        "middle_name": "S.",
        "name_prefix": "Dr.",
        "credential": "D.P.M.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-07-14",
        "last_updated": "2012-04-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "213E00000X",
            "taxonomy_group": "",
            "desc": "Podiatrist",
            "state": "PA",
            "license": "SC002170L",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "000159517",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS HMO",
            "identifier": "0048261000",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ELDER HEALTH",
            "identifier": "10766",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AMERICHOICE",
            "identifier": "0080982301",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH PARTNERS",
            "identifier": "33473",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "KEYSTONE MERCY",
            "identifier": "1000746",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Alexandra Eva Faust-Marcus, DPT
• Jessica Nicole Fields, M.D.
• Jodi Adina Finkel, M.A. CCC/SLP
• Amanda Jane Floyd, PTA
• Caitlin Rose Foley, LPC
• Barbara Elaine Foxman, LCSW
• Paul William Franzen Jr., D.C.
• Karen French, O.D.
• Leonard Friedland, M.D.
• Jeffrey M. Friedman, PHD, LCSW, QCSW

• Podiatrist in Lafayette Hill, PA
• Providers in Lafayette Hill, PA by specialty
• Podiatrist in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 27, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.