Healthcare Provider Details

I. General information

NPI: 1811121411
Provider Name (Legal Business Name): GUMTREE MEDICAL CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 BELK BLVD STE A
OXFORD MS
38655-5302
US

IV. Provider business mailing address

1306 BELK BLVD STE A
OXFORD MS
38655-5302
US

V. Phone/Fax

Practice location:
  • Phone: 662-236-6636
  • Fax: 662-236-6602
Mailing address:
  • Phone: 662-236-6636
  • Fax: 662-236-6602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY JOHN HALE
Title or Position: OWNER
Credential: M.D.
Phone: 662-236-6636