Basic Information
| Provider Information | |||||||||
| NPI: | 1144211756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIMS | ||||||||
| FirstName: | PHILLIS | ||||||||
| MiddleName: | CHERIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25317 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336225317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132860033 | ||||||||
| FaxNumber: | 8132821806 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 W LEMON ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336091104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132860033 | ||||||||
| FaxNumber: | 8132821806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301070563 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 700H262210 | 01 | BLUE CROSS-BLUE CROSS | OTHER | PM070563 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | 489790410 | 05 | MI | MEDICAID | PM070563 | 01 | CHAMPUS-CHAMPUS | OTHER |