MEDICARE: MITCHELL AND OGLESBY ANESTHESIOLOGIST ASSOCIATION PC

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	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1790234391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MITCHELL AND OGLESBY ANESTHESIOLOGIST ASSOCIATION PC

Provider Business Mailing Address
First Line	:	1075 LAFAYETTE PKWY
Second Line	:	STE 100
City	:	LAGRANGE
State	:	GA
Zip	:	30241-3584
Country	:	US
Telephone Number	:	706-940-2016
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 LAFAYETTE PKWY
Second Line	:	STE 100
City	:	LAGRANGE
State	:	GA
Zip	:	30241-3584
Country	:	US
Telephone Number	:	706-940-2016
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DAVIN G MITCHELL
Credential	:	MD
Telephone Number	:	706-940-2016

Provider Enumeration Date	:	09/25/2016
Last Update Date	:	09/25/2016

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