Healthcare Provider Details

I. General information

NPI: 1720396864
Provider Name (Legal Business Name): CROSSGATES HMA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 CROSSGATES BLVD SUITE 1500
BRANDON MS
39042-2700
US

IV. Provider business mailing address

348 CROSSGATES BLVD SUITE 1500
BRANDON MS
39042-2700
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-2360
  • Fax: 601-825-8829
Mailing address:
  • Phone: 601-824-2360
  • Fax: 601-825-8829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. STANLEY D MCLEMORE
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 239-598-3131