Healthcare Provider Details

I. General information

NPI: 1235102906
Provider Name (Legal Business Name): GINGER L POLE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4566 S EASON BLVD
TUPELO MS
38801-6540
US

IV. Provider business mailing address

PO BOX 3970
TUPELO MS
38803-3970
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-4905
  • Fax: 662-377-4906
Mailing address:
  • Phone: 662-377-4905
  • Fax: 662-377-4906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberP2154
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number02002641A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number22214
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: