Healthcare Provider Details

I. General information

NPI: 1457384687
Provider Name (Legal Business Name): LINDA KOZEL HEGSTRAND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2426 BURTON ST SE
GRAND RAPIDS MI
49546-4898
US

IV. Provider business mailing address

1125 CONLON AVE SE
GRAND RAPIDS MI
49506-3566
US

V. Phone/Fax

Practice location:
  • Phone: 616-464-0470
  • Fax: 205-350-1428
Mailing address:
  • Phone: 616-942-6584
  • Fax: 206-350-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301063871
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301063871
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: