Provider Demographics
NPI:1487246369
Name:ETHERIDGE, ANDREW JACKSON IV (CCA, CFO, CFM, CPED)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JACKSON
Last Name:ETHERIDGE
Suffix:IV
Gender:M
Credentials:CCA, CFO, CFM, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:
Practice Address - Street 1:601 N CAROLINE ST FL 6
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0006
Practice Address - Country:US
Practice Address - Phone:410-955-8215
Practice Address - Fax:410-955-1085
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologist
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter