Basic Information
| Provider Information | |||||||||
| NPI: | 1700871159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LINDER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | N15995 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | POWERS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498749608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064974360 | ||||||||
| FaxNumber: | 9064974362 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498014631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067769040 | ||||||||
| FaxNumber: | 9067747279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 01/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301080134 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1790045078 | 05 | WI | MEDICAID | 4756316 | 05 | MI | MEDICAID | P00269069 | 01 | MI | RAILROAD MEDICARE | OTHER |