Provider Demographics
NPI:1831204601
Name:JENTZ, AMY B (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:B
Last Name:JENTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-2202
Mailing Address - Country:US
Mailing Address - Phone:616-522-0714
Mailing Address - Fax:616-522-0456
Practice Address - Street 1:550 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-2202
Practice Address - Country:US
Practice Address - Phone:616-523-1630
Practice Address - Fax:616-523-1631
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAJ076427208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1016881OtherMCLAREN
MI383218134OtherTRICARE
MI4791262OtherMOLINA
MI03004OtherPRIORITY HEALTH PAY TO #
MI700C460060OtherBCBS OF MI GROUP
MI104791262Medicaid
MI200000002169OtherPHPMM
MI200000002169OtherPHPMM
MIC36179044Medicare PIN
I45425Medicare UPIN