Provider Demographics
NPI:1891794236
Name:TARBERT-SMALDONE, LISA S (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:TARBERT-SMALDONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOODWIND CT
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4119
Mailing Address - Country:US
Mailing Address - Phone:843-945-1151
Mailing Address - Fax:843-357-9818
Practice Address - Street 1:820 67TH AVE N
Practice Address - Street 2:#70692
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-2957
Practice Address - Country:US
Practice Address - Phone:843-796-3823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26891208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC268917Medicaid
SC268917Medicaid
SCI05308Medicare UPIN