Provider Demographics
NPI:1831114404
Name:LINN, ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LINN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:FEDOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:1815 E IRELAND RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-5790
Practice Address - Fax:574-647-5792
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007298A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200532590Medicaid
INP01683460OtherRR MEDICARE
IN000000941414OtherBCBS BMG BEHAVIRAL HEALTH SB
IN200532590Medicaid
IN000000944522OtherBCBS BMG LAPORTE
IN201296330Medicaid
IN201296330Medicaid
IN236040142Medicare PIN
IN000000941416OtherBCBS BMG BEHAVIORAL HEALTH ELKHART