Provider Demographics
NPI:1144224882
Name:BULTJE, MICHAEL J (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BULTJE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2093 HEALTH DR SW
Mailing Address - Street 2:STE 200
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9691
Mailing Address - Country:US
Mailing Address - Phone:616-459-3158
Mailing Address - Fax:616-819-2222
Practice Address - Street 1:2093 HEALTH DR SW
Practice Address - Street 2:STE 200
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9691
Practice Address - Country:US
Practice Address - Phone:616-459-3158
Practice Address - Fax:616-819-2222
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101014160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4426277Medicaid
MI38-2145264OtherIRS TAX ID # THRU NEW EMPLOYER EFFECTIVE 6/30/09
MI0D16122034Medicare PIN
MI4426277Medicaid