Healthcare Provider Details

I. General information

NPI: 1871749127
Provider Name (Legal Business Name): MICHAEL D. MITCHELL PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 FOOTE AVE WCA HOSPITAL
JAMESTOWN NY
14701-7077
US

IV. Provider business mailing address

28 MAPLE STREET PO BOX 41
JAMESTOWN NY
14702-0041
US

V. Phone/Fax

Practice location:
  • Phone: 716-487-1124
  • Fax:
Mailing address:
  • Phone: 716-487-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number162887
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL D MITCHELL
Title or Position: PRACTITIONER
Credential: M.D.
Phone: 716-487-1124