Healthcare Provider Details

I. General information

NPI: 1225440910
Provider Name (Legal Business Name): MICHAEL MITCHELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MEDICAL PARK STE 400 PEDIATRIC CLINIC
COLUMBIA SC
29203
US

IV. Provider business mailing address

14 MEDICAL PARK STE 400 PEDIATRIC CLINIC
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6155
  • Fax: 803-434-6979
Mailing address:
  • Phone: 803-434-6155
  • Fax: 803-434-6979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL36665
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: