Basic Information
Provider Information | |||||||||
NPI: | 1649275553 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IRICK | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2015 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | ANDERSON | ||||||||
State: | IN | ||||||||
PostalCode: | 460164337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7656468243 | ||||||||
FaxNumber: | 7656468655 | ||||||||
Practice Location | |||||||||
Address1: | 2015 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | ANDERSON | ||||||||
State: | IN | ||||||||
PostalCode: | 460164337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7656468243 | ||||||||
FaxNumber: | 7656468655 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2005 | ||||||||
LastUpdateDate: | 12/12/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | 01041583A | IN | N |   | Emergency Medical Service Providers | Personal Emergency Response Attendant |   | 207P00000X | 01028661A | IN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 200019770 | 05 | IN |   | MEDICAID | 930126119 | 01 | IN | MEDICARE RR | OTHER |