NPIMap

Individual provider Active NPI

Michael Blake Jacob, PA-C

  • Physician Assistant
  • Plymouth, MN
National Provider Identifier
1821502154
Registry record updated Mar 11, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
12593 Issued in MN
Practice address
2855 Campus Dr
Plymouth, MN 55441-2649
Phone
(763) 577-7000
NPI assigned
Nov 22, 2017
Last updated
Mar 11, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 11, 2021

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 12593 MN Primary
Sports Medicine (Orthopaedic Surgery) Physician 207XX0005X 12595 MN

Addresses

Primary practice location

2855 Campus Dr
Plymouth, MN 55441-2649

Mailing address

5600 Camerata Way Unit 221
St Louis Park, MN 55416-5285
Phone (612) 590-3809

Other practice location 1

800 E 28th St
Minneapolis, MN 55407-3723
Phone (612) 863-4000

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address mjacob362736@excellian.direct.allina.com Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20180105000060 MN Practitioner - Physician Assistant 8022377647 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Allina Health SystemGroup PAC ID 4587573613, shared by 89 NPIs, 3,844 clinicians

Practice addresses (Care Compare)

2805 Campus Dr
Suite 465
Plymouth, MN 55441-2680
Phone (952) 946-9777

2925 Chicago Ave
Minneapolis, MN 55407-1321

333 Smith Ave N
Saint Paul, MN 55102-2344
Phone (651) 241-8000

440 Elm St E
Annandale, MN 55302-1109
Phone (320) 682-5225

8100 W 78TH St
Suite 230
Edina, MN 55439-2570
Phone (952) 946-9777

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
85.6 of 100Reported as group
Quality
72.5
Promoting interoperability
100
Improvement activities
40
Cost
77.07

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
12595MNMDSports Medicine (Orthopaedic Surgery) Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Allina Health System CurrentSince Dec 31, 2022 Accepting new patients
Allina Health System CurrentSince Nov 22, 2017 Accepting new patients
Allina Health System CurrentSince Nov 22, 2017 Accepting new patients
NPI 1083910871 Past Accepting new patients

Locations

440 Elm St E
Annandale, MN 55302
Phone (320) 682-5225

2215 Park Ave
Minneapolis, MN 55404
Phone (612) 775-8800

2925 Chicago Ave
#10957
Minneapolis, MN 55407
Phone (612) 262-8640

800 E 28th St
Minneapolis, MN 55407
Phone (612) 863-3547

8100 W 78th St
Ste 230
Minneapolis, MN 55439
Phone (952) 248-5970

2855 Campus Dr
Plymouth, MN 55441
Phone (763) 577-7000

Interoperability endpoints

  • Direct secure messaging: mjacob362736@excellian.direct.allina.com

Organizations & group practices 6

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

Hospital & facility affiliations 35

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 35

NPI Registry JSON

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

{
    "created_epoch": "1511308800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1615420800000",
    "number": "1821502154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5600 CAMERATA WAY UNIT 221",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554165285",
            "telephone_number": "612-590-3809"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2855 CAMPUS DR",
            "city": "PLYMOUTH",
            "state": "MN",
            "postal_code": "554412649",
            "telephone_number": "763-577-7000"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "800 E 28th St",
            "address_purpose": "LOCATION",
            "city": "Minneapolis",
            "state": "MN",
            "postal_code": "554073723",
            "country_code": "US",
            "telephone_number": "612-863-4000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACOB",
        "first_name": "MICHAEL",
        "middle_name": "BLAKE",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-11-22",
        "last_updated": "2021-03-11",
        "certification_date": "2021-03-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "12593",
            "primary": true
        },
        {
            "code": "207XX0005X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery, Sports Medicine",
            "state": "MN",
            "license": "12595",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "mjacob362736@excellian.direct.allina.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CDA/PDF/TXT",
            "address_1": "8100 W 78th St Ste 230",
            "city": "Edina",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554392570",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Plymouth, MN

Sources for this page

Verify at the official NPI Registry.