1265402192 NPI number — DR. LINDA L REDDERSON MD

Table of content: DR. LINDA L REDDERSON MD (NPI 1265402192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265402192 NPI number — DR. LINDA L REDDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDDERSON
Provider First Name:
LINDA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIAMBALVO
Provider Other First Name:
LINDA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265402192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743294
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-855-2873
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HOLLY TREE FAMILY PRACTICE
Provider Second Line Business Practice Location Address:
11338 HIGHWAY 14
Provider Business Practice Location Address City Name:
SIMPSONVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29681-5637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-297-7091
Provider Business Practice Location Address Fax Number:
864-297-6335
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  16718 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 167189 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP2352 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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