Healthcare Provider Details

I. General information

NPI: 1083673883
Provider Name (Legal Business Name): BILLY GENE MIMS-GOODMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BILLY MIMS

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5671 PEACHTREE DUNWOODY RD NE SUITE 680
ATLANTA GA
30342-5000
US

IV. Provider business mailing address

PO BOX 740209 DEPT 1029
ATLANTA GA
30374-0209
US

V. Phone/Fax

Practice location:
  • Phone: 404-705-6985
  • Fax: 404-851-9950
Mailing address:
  • Phone: 941-360-1566
  • Fax: 941-358-9818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN134535
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: