Healthcare Provider Details

I. General information

NPI: 1770682882
Provider Name (Legal Business Name): CROSSGATES HMA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6455 HIGHWAY 18
PUCKETT MS
39151
US

IV. Provider business mailing address

5811 PELICAN BAY BLVD SUITE 500
NAPLES FL
34108-2733
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-9490
  • Fax: 601-824-9533
Mailing address:
  • Phone: 239-598-3131
  • Fax: 239-592-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL L GINGRAS
Title or Position: VICE PRESIDENT
Credential:
Phone: 239-598-3131