Provider Demographics
NPI:1477530954
Name:JENISON PODIATRY PC
Entity Type:Organization
Organization Name:JENISON PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:OOSTERHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:616-457-7171
Mailing Address - Street 1:4310 LEONARD ST NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:669 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-7903
Practice Address - Country:US
Practice Address - Phone:616-457-7171
Practice Address - Fax:616-457-1121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0307890001Medicare NSC
0G01278Medicare PIN