Provider Demographics
NPI:1760551865
Name:DERUM, LINDA A (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:DERUM
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 1:2004 ODONNELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821
Mailing Address - Country:US
Mailing Address - Phone:217-398-4443
Mailing Address - Fax:217-355-2788
Practice Address - Street 1:467 DEVONSHIRE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820
Practice Address - Country:US
Practice Address - Phone:217-398-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360812142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1022594OtherBCBS
IL213231Medicare ID - Type Unspecified