Individual
MALISSA WILSON ETHEREDGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
100 PALMETTO HEALTH PKWY STE G100, COLUMBIA, SC 29212-1754
(803) 434-1210
(803) 434-1212
Mailing address
PO BOX 743904, ATLANTA, GA 30374-3904
(803) 296-7320
(803) 296-7330
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
37102
SC
207R00000X
Internal Medicine Physician
LL37102
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
371029
—
SC
Enumeration date
06/13/2014
Last updated
12/27/2018
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