Provider Demographics
NPI:1083602924
Name:DYER ERTL, LINDA E (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:E
Last Name:DYER ERTL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:ERTL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE E352
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8986
Mailing Address - Fax:269-341-6236
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE E352
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8986
Practice Address - Fax:269-341-6236
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301095760208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1083602924Medicaid
CT001371426Medicaid
MI1417961137OtherBCBSM - BMH
CT001371426Medicaid
MIC97618237 - BMHMedicare PIN
G88551Medicare UPIN