Provider Demographics
NPI:1588007603
Name:ETHERIDGE, ROBERT NOYES (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:NOYES
Last Name:ETHERIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E CLARK ST
Mailing Address - Street 2:
Mailing Address - City:PINEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29125-8989
Mailing Address - Country:US
Mailing Address - Phone:803-774-4500
Mailing Address - Fax:803-452-5712
Practice Address - Street 1:25 E CLARK ST
Practice Address - Street 2:
Practice Address - City:PINEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29125-8989
Practice Address - Country:US
Practice Address - Phone:803-774-4500
Practice Address - Fax:803-452-5712
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine