Provider Demographics
NPI:1851304026
Name:THAMES, AMILIE T
Entity Type:Individual
Prefix:
First Name:AMILIE
Middle Name:T
Last Name:THAMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1194
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:1110 BROAD AVE STE 700
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-8908
Practice Address - Country:US
Practice Address - Phone:228-864-0314
Practice Address - Fax:228-868-8435
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21067207R00000X
MS16575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630000013Medicaid
AL011846OtherGROUP PAYEE MEDICARE NUMBER
AL1063439065OtherGROUP PAYEE NPI NUMBER