MEDICARE: JENISON PODIATRY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist

General Provider Information

NPI Number	:	1477530954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JENISON PODIATRY PC

Provider Business Mailing Address
First Line	:	4310 LEONARD ST NW
Second Line	:	SUITE 103
City	:	WALKER
State	:	MI
Zip	:	49534
Country	:	US
Telephone Number	:	616-453-6329
Fax Number	:	616-453-1725

Provider Business Practice Location Address
First Line	:	669 BALDWIN ST
Second Line	:
City	:	JENISON
State	:	MI
Zip	:	49428-7903
Country	:	US
Telephone Number	:	616-457-7171
Fax Number	:	616-457-1121

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. GENE L OOSTERHOUSE
Credential	:	DPM
Telephone Number	:	616-457-7171

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	02/01/2011

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