Individual
GREG LAURITZ ICHTERTZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
415 S 28TH AVE, HATTIESBURG, MS 39401-7246
(601) 288-4329
(601) 288-3191
Mailing address
415 S 28TH AVE, HATTIESBURG, MS 39401-7246
(601) 579-5463
(601) 579-5240
Taxonomy
Speciality
Code
Description
License number
State
208M00000X
Hospitalist Physician
Primary
19698
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04936743
—
MS
01
—
4045721
AETNA
MS
01
—
P00420680
RAILROAD MEDICARE
MS
Enumeration date
03/29/2007
Last updated
01/30/2015
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