Healthcare Provider Details

I. General information

NPI: 1972786960
Provider Name (Legal Business Name): GREGORY R MYRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 LONG STREET
MILLRY AL
36558
US

IV. Provider business mailing address

PO BOX 465
MILLRY AL
36558-0465
US

V. Phone/Fax

Practice location:
  • Phone: 251-846-3233
  • Fax: 251-846-3224
Mailing address:
  • Phone: 251-846-3233
  • Fax: 251-846-3224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number23499
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD30396
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: