MEDICARE: DR. JENNIFER MICHELLE DRISCOLL 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	207R00000X	Internal Medicine Physician	4301079562	MI
2	208000000X	Pediatrics Physician	4301079562	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1103912432	OTHER	BCBS IND PIN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	110C913020	OTHER	BCBS GRP PIN
4	157805	OTHER	GREAT LAKES HLTH PLN

General Provider Information

NPI Number	:	1609804715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER MICHELLE DRISCOLL M.D.

Provider Business Mailing Address
First Line	:	4613 W MAIN ST
Second Line	:	SUITE A
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-2645
Country	:	US
Telephone Number	:	269-488-8672
Fax Number	:	269-488-8673

Provider Business Practice Location Address
First Line	:	4613 W MAIN ST
Second Line	:	SUITE A
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-2645
Country	:	US
Telephone Number	:	269-488-8672
Fax Number	:	269-488-8673

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	12/31/2014

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Directions to “ DR. JENNIFER MICHELLE DRISCOLL M.D.” Practice Location

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