Provider Demographics
NPI:1962625822
Name:LINDA K STANLEY MD PLLC
Entity type:Organization
Organization Name:LINDA K STANLEY MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-684-8100
Mailing Address - Street 1:9 S SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2846
Mailing Address - Country:US
Mailing Address - Phone:269-684-8100
Mailing Address - Fax:269-684-8261
Practice Address - Street 1:9 S SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2846
Practice Address - Country:US
Practice Address - Phone:269-684-8100
Practice Address - Fax:269-684-8261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0801106781OtherBCBS
MI4409718Medicaid
MIA76527Medicare UPIN
MION58090Medicare ID - Type Unspecified