Healthcare Provider Details

I. General information

NPI: 1912989021
Provider Name (Legal Business Name): LINDA SUE EVANS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDA SUE BOCK

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 E MAIN ST STE B
CENTREVILLE MI
49032-8525
US

IV. Provider business mailing address

701 S HEALTH PKWY MEDICAL STAFF OFFICE
THREE RIVERS MI
49093-8352
US

V. Phone/Fax

Practice location:
  • Phone: 269-467-9011
  • Fax: 269-467-9511
Mailing address:
  • Phone: 269-273-9789
  • Fax: 269-273-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301062677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: