Healthcare Provider Details

I. General information

NPI: 1629064910
Provider Name (Legal Business Name): GREGORY S MIMS II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13833 TAPIA AVE
BAYOU LA BATRE AL
36509-2515
US

IV. Provider business mailing address

492 SUNSET BEACH RD
MORGANTOWN WV
26508-4424
US

V. Phone/Fax

Practice location:
  • Phone: 251-824-4985
  • Fax:
Mailing address:
  • Phone: 541-331-1225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD069739L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23477
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.29861
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: