Healthcare Provider Details

I. General information

NPI: 1659807410
Provider Name (Legal Business Name): ERICA EADDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 ACADEMY AVE
GREENWOOD SC
29646-3869
US

IV. Provider business mailing address

PO BOX 102321
ATLANTA GA
30368-2321
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-4865
  • Fax: 864-725-4883
Mailing address:
  • Phone: 770-801-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40940
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number85074
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: