Provider Demographics
NPI:1235185067
Name:RITSEMA, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:RITSEMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:7782 20TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8524
Practice Address - Country:US
Practice Address - Phone:616-685-8700
Practice Address - Fax:616-457-5567
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4876987Medicaid
MI3150351Medicaid
MI3415822Medicaid
MI4155675Medicaid
MI4179013Medicaid
MI4179130Medicaid
MI4179013Medicaid
MI4179130Medicaid
MIM02830047Medicare ID - Type Unspecified
MIM69390074Medicare ID - Type Unspecified