Provider Demographics
NPI:1235102906
Name:POLE, GINGER L (DO)
Entity type:Individual
Prefix:
First Name:GINGER
Middle Name:L
Last Name:POLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3970
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3970
Mailing Address - Country:US
Mailing Address - Phone:662-377-4905
Mailing Address - Fax:662-377-4906
Practice Address - Street 1:4566 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6540
Practice Address - Country:US
Practice Address - Phone:662-377-4905
Practice Address - Fax:662-377-4906
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP21542080N0001X
IN02002641A2080N0001X
MS222142080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04738364Medicaid