Provider Demographics
NPI:1265402192
Name:REDDERSON, LINDA L (MD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:L
Last Name:REDDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:L
Other - Last Name:GIAMBALVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:864-855-2873
Mailing Address - Fax:
Practice Address - Street 1:HOLLY TREE FAMILY PRACTICE
Practice Address - Street 2:11338 HIGHWAY 14
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-5637
Practice Address - Country:US
Practice Address - Phone:864-297-7091
Practice Address - Fax:864-297-6335
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC167189Medicaid
SCGP2352Medicaid
SCG08688Medicare UPIN