Healthcare Provider Details

I. General information

NPI: 1790748150
Provider Name (Legal Business Name): ADVANCED MEDICAL ASSOCIATES OF SUMMERVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 N MAIN ST
SUMMERVILLE SC
29483-7807
US

IV. Provider business mailing address

1711 N MAIN ST
SUMMERVILLE SC
29483-7807
US

V. Phone/Fax

Practice location:
  • Phone: 843-875-2268
  • Fax: 843-875-2267
Mailing address:
  • Phone: 843-875-2268
  • Fax: 843-875-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1243
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15987
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5123
License Number StateSC

VIII. Authorized Official

Name: JON LLOYD ETHERIDGE
Title or Position: PRESIDENT
Credential: DC
Phone: 843-875-2268