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General NPI Number Information
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NPI Number | 1790748150
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Entity Type | Organization
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Legal Business Name | ADVANCED MEDICAL ASSOCIATES OF SUMMERVILLE
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Dates
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Enumeration Date | 04/07/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1711 N MAIN ST
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City | SUMMERVILLE
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State | SC
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Zip | 29483-7807
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Country | US
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Telephone | 843-875-2268
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Fax | 843-875-2267
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Provider Business Mailing Address
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Address Line | 1711 N MAIN ST
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City | SUMMERVILLE
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State | SC
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Zip | 29483-7807
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Country | US
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Telephone | 843-875-2268
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Fax | 843-875-2267
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Authorized Official
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Title or Position | PRESIDENT
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Name | JON LLOYD ETHERIDGE
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Credential | DC
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Telephone | 843-875-2268
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 15987
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5123
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1243
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License Number State | SC
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