=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699931147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIE A MITCHUM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2008
-----------------------------------------------------
Last Update Date | 08/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1130 COMMERCIAL ST
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97103-4126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-325-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1130 COMMERCIAL ST
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97103-4126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-325-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1744P3200X
-----------------------------------------------------
Taxonomy Name | Prosthetics Case Management
-----------------------------------------------------
License Number | NOT REQUIRED
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------