Basic Information
| Provider Information | |||||||||
| NPI: | 1184610669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROOSSIEN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1848 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666111612 | ||||||||
| FaxNumber: | 2317284789 | ||||||||
| Practice Location | |||||||||
| Address1: | 15151 STANTON ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WEST OLIVE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494608543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162961020 | ||||||||
| FaxNumber: | 6162961030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | JR050437 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ON13120 | 01 | MI | MEDICARE GROUP NUMBER | OTHER | 4214810 | 05 | MI | MEDICAID | 1184610669 | 05 | MI | MEDICAID |