Jack Richard Roossien Jr., M.D.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

JR050437 Issued in MI

Practice address

15151 Stanton St
Suite a
West Olive, MI 49460-8543

Phone

(616) 296-1020

Fax

(616) 296-1030

NPI assigned

Sep 21, 2005

Last updated

Jun 7, 2019By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Jack R. Roossien Jr., M.D.P.C.

  • Family Medicine Physician
  • West Olive, MI
  • NPI 1740406982
  Authorized official Same address or phone
• Trinity Health Grand Haven Hospital

  • General Acute Care Hospital
  • Grand Haven, MI
  • NPI 1942379284
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1127260800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1559865600000",
    "number": "1184610669",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1848",
            "city": "MUSKEGON",
            "state": "MI",
            "postal_code": "494431848",
            "telephone_number": "866-611-1612",
            "fax_number": "231-728-4789"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15151 STANTON ST",
            "address_2": "SUITE A",
            "city": "WEST OLIVE",
            "state": "MI",
            "postal_code": "494608543",
            "telephone_number": "616-296-1020",
            "fax_number": "616-296-1030"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROOSSIEN",
        "first_name": "JACK",
        "middle_name": "RICHARD",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-09-21",
        "last_updated": "2019-06-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "JR050437",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP NUMBER",
            "identifier": "ON13120",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4214810",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1184610669",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Ronald Dean Mulder, M.D.
• Jessica Rose Phelps
• Physiotherapy Associates Inc
• Pine Ridge Adult Care Home, LLC (Pine Ridge Assisted Living Facility)
• John Alexander-Blair Ramirez, LCSW
• Jessica Lynn Roossien, FNP-BC
• Lindsey Ann Roossien, PA-C
• Mercedes B Saurbaugh, LMSW
• Patrick Schaafsma, LMSW
• Brandi Rose Sickmund, LLMSW

• Family Medicine Physician in West Olive, MI
• Providers in West Olive, MI by specialty
• Family Medicine Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 7, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.