1962596122 NPI number — DR DALE MITCHUM INC

Table of content: (NPI 1962596122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962596122 NPI number — DR DALE MITCHUM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR DALE MITCHUM INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962596122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GENEVA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36340-0900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-684-3007
Provider Business Mailing Address Fax Number:
334-684-3059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 W LAKE PROFESSIONAL PARK
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
GENEVA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36340-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-684-3007
Provider Business Practice Location Address Fax Number:
334-684-3059
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHUM
Authorized Official First Name:
DALE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER/DOCTOR
Authorized Official Telephone Number:
334-684-3007

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  12381 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 51001850 . This is a "BCBS BILLING NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 121217400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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