Provider Demographics
NPI:1386632560
Name:ETHRIDGE, CHRIS PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:PHILLIP
Last Name:ETHRIDGE
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 1:1325 E FORTIFICATION ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2442
Mailing Address - Country:US
Mailing Address - Phone:601-354-4488
Mailing Address - Fax:601-914-5188
Practice Address - Street 1:1325 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2442
Practice Address - Country:US
Practice Address - Phone:601-354-4488
Practice Address - Fax:601-914-5188
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS8332207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00100821OtherMEDICARE RR
MS00011435Medicaid
MS200000439Medicare PIN
MSP00100821OtherMEDICARE RR
MSB66034Medicare UPIN