Provider Demographics
NPI:1043671803
Name:LINC MD, PLLC
Entity type:Organization
Organization Name:LINC MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KETTERING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-781-1909
Mailing Address - Street 1:3800 BUCHTEL BOULEVARD
Mailing Address - Street 2:# 100758
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80250-0758
Mailing Address - Country:US
Mailing Address - Phone:303-781-1909
Mailing Address - Fax:720-306-2469
Practice Address - Street 1:4 GOOSEBERRY LN
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-4126
Practice Address - Country:US
Practice Address - Phone:393-781-1909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33071207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO483870Medicare PIN