Healthcare Provider Details

I. General information

NPI: 1114982485
Provider Name (Legal Business Name): GARDNER FLETCHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOSPITAL DR W
HATTIESBURG MS
39402-1346
US

IV. Provider business mailing address

200 HOSPITAL DR W
HATTIESBURG MS
39402-1346
US

V. Phone/Fax

Practice location:
  • Phone: 601-296-3000
  • Fax:
Mailing address:
  • Phone: 601-296-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10051
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number10051
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number10051
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: