Provider Demographics
NPI:1144213141
Name:EMRICK, FRED GILBERT (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:GILBERT
Last Name:EMRICK
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 1:307 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4610
Mailing Address - Country:US
Mailing Address - Phone:601-442-5042
Mailing Address - Fax:601-442-5052
Practice Address - Street 1:307 HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4610
Practice Address - Country:US
Practice Address - Phone:601-442-5042
Practice Address - Fax:601-442-5052
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS076612085R0202X
LA05908R2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0015185Medicaid
LA1535206Medicaid
MS300000167Medicare PIN
MSD80666Medicare UPIN
LA5W010Medicare PIN