Provider Demographics
NPI:1144257460
Name:DREISBACH, ALBERT W III (MD)
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:W
Last Name:DREISBACH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPT OF MEDICINE DIVISION OF NEPHROLOGY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5687
Mailing Address - Fax:601-984-5765
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE DIVISION OF NEPHROLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19442207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123182Medicaid
AL156408Medicaid
AL116796Medicaid
LA1487872Medicaid
MS110002000Medicare PIN
MS00123182Medicaid
MSP00679672Medicare PIN
AL116796Medicaid
LA1487872Medicaid