Provider Demographics
NPI:1366531162
Name:ETHERIDGE, TRICIA L (MD)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-9165
Mailing Address - Country:US
Mailing Address - Phone:843-726-6773
Mailing Address - Fax:843-726-6778
Practice Address - Street 1:109 S GREEN ST
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-9165
Practice Address - Country:US
Practice Address - Phone:843-726-6773
Practice Address - Fax:843-726-6778
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19547208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC320114664OtherBLUE CROSS BLUE SHIELD
SC42D1028556OtherCLIA
SCDC4084OtherRAIL ROAD MEDICARE
SC320114664OtherTAX ID
SC19547OtherLICENSE #
SCL25587Medicaid
SCG90310Medicare UPIN
SCL25587Medicaid