Provider Demographics
NPI:1154431351
Name:GRUICH, MITCHELL J (MD, FAAP)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:J
Last Name:GRUICH
Suffix:
Gender:M
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2356 PASS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2236
Mailing Address - Country:US
Mailing Address - Phone:228-385-1711
Mailing Address - Fax:228-385-3333
Practice Address - Street 1:2356 PASS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2236
Practice Address - Country:US
Practice Address - Phone:228-385-1711
Practice Address - Fax:228-385-3333
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13525208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115028Medicaid