Provider Demographics
NPI:1972786960
Name:MYRICK, GREGORY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:MYRICK
Suffix:
Gender:M
Credentials:MD
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 465
Mailing Address - Street 2:
Mailing Address - City:MILLRY
Mailing Address - State:AL
Mailing Address - Zip Code:36558-0465
Mailing Address - Country:US
Mailing Address - Phone:251-846-3233
Mailing Address - Fax:251-846-3224
Practice Address - Street 1:73 LONG STREET
Practice Address - Street 2:
Practice Address - City:MILLRY
Practice Address - State:AL
Practice Address - Zip Code:36558
Practice Address - Country:US
Practice Address - Phone:251-846-3233
Practice Address - Fax:251-846-3224
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23499207P00000X
390200000X
ALMD30396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL181032Medicaid