Healthcare Provider Details

I. General information

NPI: 1730260613
Provider Name (Legal Business Name): GREGORY TIMBERLAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

PO BOX 3287
JACKSON MS
39207-3287
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1000
  • Fax: 601-815-4570
Mailing address:
  • Phone: 601-984-1000
  • Fax: 601-815-4570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number17108
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number17108
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: