Healthcare Provider Details

I. General information

NPI: 1740406982
Provider Name (Legal Business Name): JACK R. ROOSSIEN JR., M.D.P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15151 STANTON ST SUITE A
WEST OLIVE MI
49460-8543
US

IV. Provider business mailing address

15151 STANTON ST SUITE A
WEST OLIVE MI
49460-8543
US

V. Phone/Fax

Practice location:
  • Phone: 616-296-1020
  • Fax: 616-296-1030
Mailing address:
  • Phone: 616-296-1020
  • Fax: 616-296-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301050437
License Number StateMI

VIII. Authorized Official

Name: DR. JACK RICHARD ROOSSIEN JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 616-296-1020