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NPI Code Detail

MEDICARE: JILL MIEDEMA MD

MEDICARE: JILL MIEDEMA MD
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
1207Q00000XFamily Medicine Physician51202MN

General Provider Information

NPI Number : 1083737969
Entity Type Code : Individual
Provider Name (Legal Business Name) : JILL MIEDEMA MD
Provider Business Mailing Address
First Line : 17581 DUNESIDE DR
Second Line :
City : GRAND HAVEN
State : MI
Zip : 49417-8883
Country : US
Telephone Number : 517-803-9493
Fax Number :
Provider Business Practice Location Address
First Line : 382 120TH AVE
Second Line :
City : HOLLAND
State : MI
Zip : 49424-2169
Country : US
Telephone Number : 616-396-6516
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/07/2007
Last Update Date : 07/30/2012

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