Provider Demographics
NPI:1154365518
Name:MICKLOW, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MICKLOW
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 305172
Mailing Address - Street 2:DEPT # 109
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-5172
Mailing Address - Country:US
Mailing Address - Phone:931-647-5034
Mailing Address - Fax:931-552-6663
Practice Address - Street 1:100 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3927
Practice Address - Country:US
Practice Address - Phone:931-647-5034
Practice Address - Fax:931-552-6663
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL81596207P00000X
TN45339207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL196453355OtherCHAMPUS
FL06040OtherBLUE SHIELD OF FL
FL264082100Medicaid
FL196453355OtherCHAMPUS
FL06040YMedicare ID - Type Unspecified
FL264082100Medicaid