Basic Information
| Provider Information | |||||||||
| NPI: | 1275501132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIMS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102966 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702371561 | ||||||||
| FaxNumber: | 7702371124 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 EAGLES LANDING PKWY | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302815085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703892200 | ||||||||
| FaxNumber: | 7703891124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 10/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 045298 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.