=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679873723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEADVILLE URGENT CARE PHYSICIANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2010
-----------------------------------------------------
Last Update Date | 11/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16332 CONNEAUT LAKE RD
-----------------------------------------------------
City | MEADVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16335-3843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-807-0670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 61
-----------------------------------------------------
City | MEADVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16335-0061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-807-0670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS MITCHELL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 814-807-0670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------