Malissa Wilson Etheredge, M.D.

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

37102 Issued in SC

Practice address

100 Palmetto Health Pkwy Ste G100
Columbia, SC 29212-1754

Phone

(803) 434-1210

Fax

(803) 434-1212

NPI assigned

Jun 13, 2014

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Malissa Blair Wilson Former name

Medicare fee-for-service enrollment

Enrolled in SC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: metheredge378953@direct.ghs.myhfn.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Prisma Health Medical Group-Midlands

  • Multi-Specialty Clinic/Center
  • Columbia, SC
  • NPI 1275988321

  Internal Medicine

  Medicare reassignment NPD
• Palmetto Health - University of South Carolina Medical Group

  • Family Medicine Physician
  • Sumter, SC
  • NPI 1295211894
  NPD
• Prisma Health Medical Group-Midlands

  • Durable Medical Equipment & Medical Supplies
  • Columbia, SC
  • NPI 1881469856
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1402617600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1545868800000",
    "number": "1811301203",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 743904",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303743904",
            "telephone_number": "803-296-7320",
            "fax_number": "803-296-7330"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 PALMETTO HEALTH PKWY STE G100",
            "city": "COLUMBIA",
            "state": "SC",
            "postal_code": "292121754",
            "telephone_number": "803-434-1210",
            "fax_number": "803-434-1212"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1801 Sunset Drive",
            "address_2": "Internal Medicine Clinic",
            "address_purpose": "LOCATION",
            "city": "Columbia",
            "state": "SC",
            "postal_code": "29203",
            "country_code": "US",
            "telephone_number": "803-434-4153",
            "fax_number": "803-434-4160",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "ETHEREDGE",
        "first_name": "MALISSA",
        "middle_name": "WILSON",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2014-06-13",
        "last_updated": "2018-12-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "SC",
            "license": "LL37102",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "SC",
            "license": "37102",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "371029",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MALISSA",
            "last_name": "WILSON",
            "middle_name": "BLAIR",
            "credential": "MD",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Essential Psychiatry and Wellness
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• Bridget D Etheredge
• Moncina Etheredge, LMP
• Anthony Wayne Etheridge, RDH
• Ginger Marie Eubank, PHARMD
• Cassey Eunice, PHARMD
• Evans Counseling and Consulting, Inc

• Internal Medicine Physician in Columbia, SC
• Providers in Columbia, SC by specialty
• Internal Medicine Physician in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 27, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.