Basic Information
| Provider Information | |||||||||
| NPI: | 1386632560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETHRIDGE | ||||||||
| FirstName: | CHRIS | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
| FaxNumber: | 6019145188 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
| FaxNumber: | 6019145188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 8332 | MS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00100821 | 01 | MS | MEDICARE RR | OTHER | 00011435 | 05 | MS | MEDICAID |