Healthcare Provider Details

I. General information

NPI: 1588007603
Provider Name (Legal Business Name): ROBERT NOYES ETHERIDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 E CLARK ST
PINEWOOD SC
29125-8989
US

IV. Provider business mailing address

25 E CLARK ST
PINEWOOD SC
29125-8989
US

V. Phone/Fax

Practice location:
  • Phone: 803-774-4500
  • Fax: 803-452-5712
Mailing address:
  • Phone: 803-774-4500
  • Fax: 803-452-5712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40082
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: