MEDICARE: THE COUNTRY DOCTOR, LTD.

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	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1750553749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE COUNTRY DOCTOR, LTD.

Provider Business Mailing Address
First Line	:	2310 COUNTRY RD
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-2570
Country	:	US
Telephone Number	:	618-277-3197
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 COUNTRY RD
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-2570
Country	:	US
Telephone Number	:	618-277-3197
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN/PRESIDENT
Name	:	DR. DAVID LARRY MITCHELL
Credential	:	M.D.
Telephone Number	:	618-277-3197

Provider Enumeration Date	:	03/31/2008
Last Update Date	:	03/31/2008

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Directions to “THE COUNTRY DOCTOR, LTD. ” Practice Location

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