=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861140790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOEBE B. MITCHELL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2022
-----------------------------------------------------
Last Update Date | 03/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BROOKLINE PL STE 423
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02445-7237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-566-1535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 CAROLINA AVE # 2
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-3213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-492-6519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PHOEBE BACON MITCHELL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 781-492-6519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------