Provider Demographics
NPI:1528020229
Name:JEN MED PROF LLC
Entity Type:Organization
Organization Name:JEN MED PROF LLC
Other - Org Name:STURGIS MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:JENTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:605-347-3684
Mailing Address - Street 1:1010 BALLPARK RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-2364
Mailing Address - Country:US
Mailing Address - Phone:605-347-3684
Mailing Address - Fax:605-347-0083
Practice Address - Street 1:1010 BALLPARK RD
Practice Address - Street 2:SUITE 2
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-2364
Practice Address - Country:US
Practice Address - Phone:605-347-3684
Practice Address - Fax:605-347-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD142389900OtherOWCP PROVIDER
SD42339OtherRADIATION MEDICAL LICENSE
SD14172-1OtherFAA LICENSE NUMBER
SD5602360OtherTITLE 19
SDS2312OtherMEDICARE PTAN
SD1034OtherPHYSICIAN'S LICENSE
SD43D0408177OtherCLIA LAB
SDD25381OtherDEA
SD43D0408177OtherCLIA LAB
SDD25381Medicare UPIN