Provider Demographics
NPI:1497791610
Name:WELLS, JASON (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-267-8244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301511234207RP1001X, 207RC0200X
ORMD157009207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500645778Medicaid
OR500645778Medicaid
COCQ2008Medicare PIN
OR500645778Medicaid
OR164920Medicare PIN
CO04594040Medicaid