Provider Demographics
NPI:1881749489
Name:ETHRIDGE, HEBER CLARK JR (MD)
Entity type:Individual
Prefix:
First Name:HEBER
Middle Name:CLARK
Last Name:ETHRIDGE
Suffix:JR
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 1:1151 N STATE ST
Mailing Address - Street 2:SUITE 311
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-969-1171
Mailing Address - Fax:601-969-1173
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:SUITE 311
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-969-1171
Practice Address - Fax:601-969-1173
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08726207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011327Medicaid
D62929Medicare UPIN
MS00011327Medicaid