Healthcare Provider Details

I. General information

NPI: 1336245349
Provider Name (Legal Business Name): TRISTAN K LINEBERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E MAIN ST
PROVIDENCE KY
42450-1261
US

IV. Provider business mailing address

PO BOX 37
PROVIDENCE KY
42450-0037
US

V. Phone/Fax

Practice location:
  • Phone: 270-667-7017
  • Fax:
Mailing address:
  • Phone: 270-667-7017
  • Fax: 270-667-9065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21614
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: