1568414241 NPI number — JILL BULTJE MD

Table of content: JILL BULTJE MD (NPI 1568414241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568414241 NPI number — JILL BULTJE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BULTJE
Provider First Name:
JILL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568414241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 STATE ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-4328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-685-1808
Provider Business Mailing Address Fax Number:
616-685-1850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1471 E BELTLINE AVE NE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525-4548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-685-8620
Provider Business Practice Location Address Fax Number:
676-447-7674
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301074566 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4876996 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4440310 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4440347 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4440338 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4440300 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4440329 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4548162 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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