Healthcare Provider Details

I. General information

NPI: 1124512454
Provider Name (Legal Business Name): PHILLIPS RUTH DERIDDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RICHLAND MEDICAL PARK DR STE 530
COLUMBIA SC
29203-6870
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4603
  • Fax: 803-434-7983
Mailing address:
  • Phone: 864-695-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLL52457
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number52457
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL52457
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: