Healthcare Provider Details

I. General information

NPI: 1982051660
Provider Name (Legal Business Name): MARY MORGAN MITCHELL D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 INNOVATION DR STE 2100
BLACKSBURG VA
24060-6618
US

IV. Provider business mailing address

PO BOX 1088
PULASKI VA
24301-1088
US

V. Phone/Fax

Practice location:
  • Phone: 540-232-8405
  • Fax:
Mailing address:
  • Phone: 540-980-0922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102205725
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101022404
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102205725
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: