Basic Information
| Provider Information | |||||||||
| NPI: | 1124117171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLESPIE | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015795463 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 PARKWAY LN | ||||||||
| Address2: | |||||||||
| City: | PETAL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394653035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015447404 | ||||||||
| FaxNumber: | 6015846457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 01/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 19284 | MS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 19284 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05020034 | 05 | MS | MEDICAID | 0029455 | 01 | MS | CIGNA | OTHER | 9864055 | 01 | MS | AETNA | OTHER | 6039505 | 01 | MS | HEALTHSPRING | OTHER | BG9704645 | 01 | DEA # | OTHER |