Provider Demographics
NPI:1205872876
Name:GIRISH, MIRLE R (MD)
Entity type:Individual
Prefix:
First Name:MIRLE
Middle Name:R
Last Name:GIRISH
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 1:2205 PAVILION DR
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4641
Mailing Address - Country:US
Mailing Address - Phone:423-857-7650
Mailing Address - Fax:423-857-7655
Practice Address - Street 1:2205 PAVILION DR
Practice Address - Street 2:SUITE 201B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4641
Practice Address - Country:US
Practice Address - Phone:423-857-7650
Practice Address - Fax:423-857-7655
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35140207RC0200X, 207RP1001X
TN34140207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205872876Medicaid
TN1530376Medicaid
TN3865759Medicaid
TN3865758Medicaid
KY7100113230Medicaid
TN3865759Medicaid
TN3865758Medicare PIN
TN103I291725Medicare PIN