Basic Information
| Provider Information | |||||||||
| NPI: | 1821211665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYNES | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 ENTERPRISE PKWY | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236666251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572517700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 01/01/2016 | ||||||||
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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 | 20704 | WV | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 0101242161 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1821211665 | 01 | WV | MOUNTAIN STATE BLUE CROSS BLUE SHIELD | OTHER | P01036106 | 01 | VA | RAILROAD MEDICARE | OTHER | 270052997 | 01 | WV | HEALTHNET/TRICARE | OTHER | FM0470295 | 01 | WV | DEA | OTHER | 1821211665 | 05 | VA | MEDICAID | 3810011144 | 05 | WV | MEDICAID |