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NPI Code Detail

MEDICARE: JOHN BRUCE ETHERIDGE MD

MEDICARE: JOHN BRUCE ETHERIDGE MD
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics Physician19936SC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1861586414
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN BRUCE ETHERIDGE MD
Provider Business Mailing Address
First Line : 721 OKATIE HWY
Second Line :
City : OKATIE
State : SC
Zip : 29909-3963
Country : US
Telephone Number : 843-987-7400
Fax Number :
Provider Business Practice Location Address
First Line : 1320 RIBAUT RD
Second Line :
City : PORT ROYAL
State : SC
Zip : 29935-1118
Country : US
Telephone Number : 843-986-0900
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/03/2006
Last Update Date : 06/16/2026

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Directions to “ JOHN BRUCE ETHERIDGE MD” Practice Location

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