Provider Demographics
NPI:1649275553
Name:IRICK, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:IRICK
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 1:2015 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4337
Mailing Address - Country:US
Mailing Address - Phone:765-646-8243
Mailing Address - Fax:765-646-8655
Practice Address - Street 1:2015 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4337
Practice Address - Country:US
Practice Address - Phone:765-646-8243
Practice Address - Fax:765-646-8655
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041583A146D00000X
IN01028661A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200019770Medicaid
IN930126119OtherMEDICARE RR
INF71310Medicare UPIN
IN200019770Medicaid