Healthcare Provider Details

I. General information

NPI: 1154431351
Provider Name (Legal Business Name): MITCHELL J GRUICH M.D., F.A.A.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2356 PASS RD SUITE 300
BILOXI MS
39531-2236
US

IV. Provider business mailing address

2356 PASS RD SUITE 300
BILOXI MS
39531-2236
US

V. Phone/Fax

Practice location:
  • Phone: 228-385-1711
  • Fax: 228-385-3333
Mailing address:
  • Phone: 228-385-1711
  • Fax: 228-385-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13525
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: