Basic Information
| Provider Information | |||||||||
| NPI: | 1568414241 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULTJE | ||||||||
| FirstName: | JILL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | 6166851850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1471 E BELTLINE AVE NE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495254548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858620 | ||||||||
| FaxNumber: | 6764477674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 06/26/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301074566 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4876996 | 05 | MI | MEDICAID | 4440310 | 05 | MI | MEDICAID | 4440347 | 05 | MI | MEDICAID | 4440338 | 05 | MI | MEDICAID | 4440300 | 05 | MI | MEDICAID | 4440329 | 05 | MI | MEDICAID | 4548162 | 05 | MI | MEDICAID |