MEDICARE: DR. JACK RICHARD ROOSSIEN JR. M.D.

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	207Q00000X	Family Medicine Physician	JR050437	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ON13120	OTHER	MI	MEDICARE GROUP NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184610669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK RICHARD ROOSSIEN JR. M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1848
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49443-1848
Country	:	US
Telephone Number	:	866-611-1612
Fax Number	:	231-728-4789

Provider Business Practice Location Address
First Line	:	15151 STANTON ST
Second Line	:	SUITE A
City	:	WEST OLIVE
State	:	MI
Zip	:	49460-8543
Country	:	US
Telephone Number	:	616-296-1020
Fax Number	:	616-296-1030

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

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	06/07/2019

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Directions to “ DR. JACK RICHARD ROOSSIEN JR. M.D.” Practice Location

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