Provider Demographics
NPI:1790748150
Name:ADVANCED MEDICAL ASSOCIATES OF SUMMERVILLE
Entity Type:Organization
Organization Name:ADVANCED MEDICAL ASSOCIATES OF SUMMERVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:ETHERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-875-2268
Mailing Address - Street 1:1711 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-7807
Mailing Address - Country:US
Mailing Address - Phone:843-875-2268
Mailing Address - Fax:843-875-2267
Practice Address - Street 1:1711 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7807
Practice Address - Country:US
Practice Address - Phone:843-875-2268
Practice Address - Fax:843-875-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1243111N00000X
SC15987208D00000X
SC5123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4385Medicaid
SC2015987OtherCDS
SCCH1243Medicaid
SCCH1243Medicaid