| Doctor Name: | JACOB EDIBA |
| NPI Number: | 1871950782 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D |
| License Number: | MCS-10-0005-0464R1 |
| Business Practice Address: | 273 Keystone Dr Apt 5 Rantoul, IL - 618662774 |
| Business Phone Number: | 2174187384 |
| Business Fax Number: | |
| Mailing Address: | 273 Keystone Dr Apt 5, RANTOUL |
| State: | IL |
| Postal Code: | 618662774 |
| Phone Number: | 2174187384 |
| Fax Number: | |
| NPI Enumeration Date: | 01/22/2016 |
| NPI Last Update Date: | 01/22/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 343900000X |
| License Number: | MCS-10-0005-0464R1 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Transportation Services |
| Taxonomy Classification: | Non-emergency Medical Transport (VAN) |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A land vehicle with a capacity to meet special height, clearance, access, and seating, for the conveyance of persons in non-emergency situations. The vehicle may or may not be required to meet local county or state regulations. |