MEDICARE: IDOL RAY MITCHELL DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	016-004683	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	480034728	OTHER		RAILROAD MEDICARE PROV #
4	214428	OTHER	IL	MEDICARE ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4452210001	OTHER		DMERC
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508850694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDOL RAY MITCHELL DPM

Provider Business Mailing Address
First Line	:	437 EAST GRANT STREET
Second Line	:
City	:	MACOMB
State	:	IL
Zip	:	61455-3352
Country	:	US
Telephone Number	:	309-837-3964
Fax Number	:	309-837-3966

Provider Business Practice Location Address
First Line	:	437 EAST GRANT STREET
Second Line	:
City	:	MACOMB
State	:	IL
Zip	:	61455-3352
Country	:	US
Telephone Number	:	309-837-3964
Fax Number	:	309-837-3966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	05/15/2008

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Directions to “ IDOL RAY MITCHELL DPM” Practice Location

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