Basic Information
Provider Information | |||||||||
NPI: | 1831197672 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCGEE | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | SULLIVAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2101 HIGHWAY 90 | ||||||||
Address2: |   | ||||||||
City: | GAUTIER | ||||||||
State: | MS | ||||||||
PostalCode: | 395535340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2284977576 | ||||||||
FaxNumber: | 2284978869 | ||||||||
Practice Location | |||||||||
Address1: | 4300 HOSPITAL ST STE 106 | ||||||||
Address2: |   | ||||||||
City: | PASCAGOULA | ||||||||
State: | MS | ||||||||
PostalCode: | 395815306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288095380 | ||||||||
FaxNumber: | 2288095386 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2005 | ||||||||
LastUpdateDate: | 05/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 00015677 | AL | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 24292 | MS | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 00118976 | 05 | MS |   | MEDICAID |