Healthcare Provider Details

I. General information

NPI: 1710113550
Provider Name (Legal Business Name): MATTHEW D MITCHELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 08/05/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRUCE ST
PHILADELPHIA PA
19107-6130
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD STE 220
RED BANK NJ
07701-5792
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-3867
  • Fax: 215-829-5567
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ00363700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN573737
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: