Provider Demographics
NPI:1912989021
Name:EVANS, LINDA SUE (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:SUE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:SUE
Other - Last Name:BOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 S HEALTH PKWY
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-8352
Mailing Address - Country:US
Mailing Address - Phone:269-273-9789
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:677 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-8525
Practice Address - Country:US
Practice Address - Phone:269-467-9011
Practice Address - Fax:269-467-9511
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062677208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3525600 10Medicaid
MI700G560080OtherBCBSM
MID69425Medicare UPIN
MI3525600 10Medicaid