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General NPI Number Information
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NPI Number | 1962439109
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Entity Type | Individual
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Provider Name | ETHAN CHRISTIAN RICHARD D.O
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Gender | Male
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Dates
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Enumeration Date | 06/26/2006
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 885 GOLD HILL RD STE 506
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City | FORT MILL
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State | SC
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Zip | 29708-7946
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Country | US
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Telephone | 804-869-0341
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Fax |
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Provider Business Mailing Address
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Address Line | 10840 VALLEY HILL RD
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City | FORT MILL
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State | SC
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Zip | 29707-7452
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Country | US
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Telephone | 913-291-7173
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 82176
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2006025644
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2019-01089
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License Number State | NC
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