Provider Demographics
NPI:1881779684
Name:LINE, MICHAEL R (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:LINE
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1200 PLEASANT STREET
Mailing Address - Street 2:BLANK CHILDREN'S HOSPITAL
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1453
Mailing Address - Country:US
Mailing Address - Phone:515-241-5926
Mailing Address - Fax:515-241-5127
Practice Address - Street 1:1200 PLEASANT STREET
Practice Address - Street 2:BLANK CHILDREN'S HOSPITAL
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1453
Practice Address - Country:US
Practice Address - Phone:515-241-5926
Practice Address - Fax:515-241-5127
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2009-06-24
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Provider Licenses
StateLicense IDTaxonomies
IA38276208000000X
CO428482080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1881779684Medicaid
CO88803813Medicaid