Provider Demographics
NPI:1811121411
Name:GUMTREE MEDICAL CLINIC, PLLC
Entity type:Organization
Organization Name:GUMTREE MEDICAL CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-236-6636
Mailing Address - Street 1:1306 BELK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5302
Mailing Address - Country:US
Mailing Address - Phone:662-236-6636
Mailing Address - Fax:662-236-6602
Practice Address - Street 1:1306 BELK BLVD STE A
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5302
Practice Address - Country:US
Practice Address - Phone:662-236-6636
Practice Address - Fax:662-236-6602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty