Healthcare Provider Details

I. General information

NPI: 1104815323
Provider Name (Legal Business Name): WINSTON A MITCHELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 E 93RD ST
CHICAGO IL
60617-3909
US

IV. Provider business mailing address

8600 N STATE ROUTE 91 STE 250
PEORIA IL
61615-9506
US

V. Phone/Fax

Practice location:
  • Phone: 773-967-2000
  • Fax:
Mailing address:
  • Phone: 309-692-5393
  • Fax: 309-692-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01077886A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036103962
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036103962
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036103962
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: