Healthcare Provider Details

I. General information

NPI: 1194756676
Provider Name (Legal Business Name): ROBERT LACOUR MITCHELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1266 HIGHWAY 515 S
JASPER GA
30143
US

IV. Provider business mailing address

1584 TIMBERLAND RD NE
ATLANTA GA
30345-4163
US

V. Phone/Fax

Practice location:
  • Phone: 706-692-2441
  • Fax: 706-301-5352
Mailing address:
  • Phone: 404-633-1261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number047491
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number047491
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number047491
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: