Individual
TRICIA L ETHERIDGE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
109 S GREEN ST, RIDGELAND, SC 29936-9165
(843) 726-6773
(843) 726-6778
Mailing address
109 S GREEN ST, RIDGELAND, SC 29936-9165
(843) 726-6773
(843) 726-6778
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
19547
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
19547
LICENSE #
SC
01
—
320114664
BLUE CROSS BLUE SHIELD
SC
01
—
42D1028556
CLIA
SC
01
—
DC4084
RAIL ROAD MEDICARE
SC
05
—
L25587
—
SC
Enumeration date
10/12/2006
Last updated
12/14/2015
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