Provider Demographics
NPI:1588654263
Name:JELSEMA, RUSSEL D (MD)
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:D
Last Name:JELSEMA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGAN ST NE
Practice Address - Street 2:SUITE 600
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2543
Practice Address - Country:US
Practice Address - Phone:616-774-7035
Practice Address - Fax:616-774-4057
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIRJ407131174400000X
MI4301407131207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3370524Medicaid
MIE77770Medicare UPIN