Healthcare Provider Details

I. General information

NPI: 1750597027
Provider Name (Legal Business Name): JENNIFER ANNE HULTMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ANNE CLIFT MD

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MICHIGAN ST NE SUITE 525
GRAND RAPIDS MI
49503-2528
US

IV. Provider business mailing address

2721 RUM CREEK DR SE
KENTWOOD MI
49508-5279
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3776
  • Fax:
Mailing address:
  • Phone: 616-971-8000
  • Fax: 616-971-8000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301081919
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301081919
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: