MEDICARE: JILL BULTJE MD

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301074566	MI

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1568414241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL BULTJE MD

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

Provider Business Practice Location Address
First Line	:	1471 E BELTLINE AVE NE
Second Line	:	SUITE 201
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-4548
Country	:	US
Telephone Number	:	616-685-8620
Fax Number	:	676-447-7674

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	06/26/2009