Healthcare Provider Details

I. General information

NPI: 1881749489
Provider Name (Legal Business Name): HEBER CLARK ETHRIDGE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N STATE ST SUITE 311
JACKSON MS
39202
US

IV. Provider business mailing address

1151 N STATE ST SUITE 311
JACKSON MS
39202-2407
US

V. Phone/Fax

Practice location:
  • Phone: 601-969-1171
  • Fax: 601-969-1173
Mailing address:
  • Phone: 601-969-1171
  • Fax: 601-969-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number08726
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: