Healthcare Provider Details

I. General information

NPI: 1316147572
Provider Name (Legal Business Name): JOHN B MITCHELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MID TOWNE ST NE STE 304
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

1000 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3663
US

V. Phone/Fax

Practice location:
  • Phone: 215-746-7222
  • Fax:
Mailing address:
  • Phone: 215-746-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMT184675
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301095335
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: