Provider Demographics
NPI:1366483919
Name:LINDYBERG, KENNETH RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAYMOND
Last Name:LINDYBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 GREENE RD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MD
Mailing Address - Zip Code:21013-9102
Mailing Address - Country:US
Mailing Address - Phone:410-557-0451
Mailing Address - Fax:
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:SUITE 4430
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204
Practice Address - Country:US
Practice Address - Phone:443-849-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47056207R00000X
MDD0047056208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D30070Medicare UPIN
146QMedicare ID - Type Unspecified