Basic Information
| Provider Information | |||||||||
| NPI: | 1730260613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIMBERLAKE | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3287 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392073287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841000 | ||||||||
| FaxNumber: | 6018154570 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841000 | ||||||||
| FaxNumber: | 6018154570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
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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 | 208600000X | 17108 | MS | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 17108 | MS | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 00123637 | 05 | MS | MEDICAID | P01233200 | 01 | MS | RAILROAD MEDICARE | OTHER |