Provider Demographics
NPI:1588618953
Name:VANDENBOSCH, LINDA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:VANDENBOSCH
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 1:100 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 1:8501 MEADOW CRK
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7524
Practice Address - Country:US
Practice Address - Phone:616-825-7625
Practice Address - Fax:616-884-2995
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4773854Medicaid
MI1598712390OtherGROUP NPI
MI4769341Medicaid
MI4769127Medicaid
MI4773980Medicaid
MI0804113501OtherBCBS
MI4769323Medicaid
MIP00278296Medicare ID - Type UnspecifiedRAILROAD
MI1598712390OtherGROUP NPI