Basic Information
| Provider Information | |||||||||
| NPI: | 1881779684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 PLEASANT STREET | ||||||||
| Address2: | BLANK CHILDREN'S HOSPITAL | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152415926 | ||||||||
| FaxNumber: | 5152415127 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 PLEASANT STREET | ||||||||
| Address2: | BLANK CHILDREN'S HOSPITAL | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152415926 | ||||||||
| FaxNumber: | 5152415127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 38276 | IA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 42848 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1881779684 | 05 | IA | MEDICAID | 88803813 | 05 | CO | MEDICAID |