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General NPI Number Information
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NPI Number | 1629064910
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Entity Type | Individual
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Provider Name | GREGORY S MIMS II MD
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Gender | Male
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Dates
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Enumeration Date | 09/22/2005
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 13833 TAPIA AVE
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City | BAYOU LA BATRE
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State | AL
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Zip | 36509-2515
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Country | US
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Telephone | 251-824-4985
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Fax |
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Provider Business Mailing Address
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Address Line | 492 SUNSET BEACH RD
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City | MORGANTOWN
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State | WV
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Zip | 26508-4424
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Country | US
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Telephone | 541-331-1225
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD069739L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 23477
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License Number State | WV
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD.29861
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License Number State | AL
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