Provider Demographics
NPI:1740406982
Name:JACK R. ROOSSIEN JR., M.D.P.C.
Entity Type:Organization
Organization Name:JACK R. ROOSSIEN JR., M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ROOSSIEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:616-296-1020
Mailing Address - Street 1:15151 STANTON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-8543
Mailing Address - Country:US
Mailing Address - Phone:616-296-1020
Mailing Address - Fax:616-296-1030
Practice Address - Street 1:15151 STANTON ST
Practice Address - Street 2:SUITE A
Practice Address - City:WEST OLIVE
Practice Address - State:MI
Practice Address - Zip Code:49460-8543
Practice Address - Country:US
Practice Address - Phone:616-296-1020
Practice Address - Fax:616-296-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION13120OtherMEDICARE GROUP NUMBER
MI4214810Medicaid
MI4214810Medicaid
MIE34750Medicare UPIN