MEDICARE: ANDREW JACKSON ETHERIDGE IV CCA, CFO, CFM, CPED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	156FX1700X	Ocularist
2	224900000X	Mastectomy Fitter
3	224L00000X	Pedorthist
4	225000000X	Orthotic Fitter
5	229N00000X	Anaplastologist

General Provider Information

NPI Number	:	1487246369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW JACKSON ETHERIDGE IV CCA, CFO, CFM, CPED

Provider Business Mailing Address
First Line	:	6201 GREENLEIGH AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21220-2004
Country	:	US
Telephone Number	:	410-933-6423
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 N CAROLINE ST FL 6
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21287-0006
Country	:	US
Telephone Number	:	410-955-8215
Fax Number	:	410-955-1085

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2021
Last Update Date	:	08/30/2022

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