Provider Demographics
NPI:1336245349
Name:LINEBERRY, TRISTAN K (MD)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:K
Last Name:LINEBERRY
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:42450-0037
Mailing Address - Country:US
Mailing Address - Phone:270-667-7017
Mailing Address - Fax:270-667-9065
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1261
Practice Address - Country:US
Practice Address - Phone:270-667-7017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY21614OtherLICENSE
000000044292OtherBCBS PROVIDER NUMBER
KY64216146Medicaid
KY64216146Medicaid
C67018Medicare UPIN
KY080104189Medicare PIN