Provider Demographics
NPI:1578620480
Name:TRICIA ETHERIDGE, MD, PC
Entity Type:Organization
Organization Name:TRICIA ETHERIDGE, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MURDAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-726-6773
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-2616
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3946Medicaid
SC50017139OtherTAT
SC42D1028556OtherCLIA
SCL25587Medicaid
SCL25587Medicaid
SC8009Medicare PIN
SCBE4935308OtherDEA