Basic Information
| Provider Information | |||||||||
| NPI: | 1063674661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETHERIDGE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 NW 1ST LN | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647598105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176815100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 29 NW 1ST LN | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647598105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176815100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2012003246 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 440552485 | 01 | MO | TRICARE | OTHER | 1063674661 | 05 | MO | MEDICAID | P01119720 | 01 | MO | RR MCR | OTHER |