Basic Information
| Provider Information | |||||||||
| NPI: | 1164414546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINDABERRY | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | SAMUEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 FINNEGAN CT | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439039993 | ||||||||
| FaxNumber: | 8439033356 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 FINNEGAN CT | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439039993 | ||||||||
| FaxNumber: | 8439033356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 712 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 007129 | 05 | SC | MEDICAID | 712 | 01 | SC | MEDICAL LICENSE | OTHER |