Provider Demographics
NPI:1255300968
Name:BOSCH, JAMIE D (MD)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:D
Last Name:BOSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JAMIE
Other - Middle Name:D
Other - Last Name:CROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8485 ALGOMA AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9102
Mailing Address - Country:US
Mailing Address - Phone:616-863-6220
Mailing Address - Fax:616-863-6221
Practice Address - Street 1:1200 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9704
Practice Address - Country:US
Practice Address - Phone:616-243-5707
Practice Address - Fax:616-243-1170
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070047208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4738256Medicaid
MI4236290Medicaid
MI11272379OtherCAQH
MI4236290Medicaid