1194791186 NPI number — WILLIAM A MITCHELL JR. M.D.

Table of content: WILLIAM A MITCHELL JR. M.D. (NPI 1194791186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194791186 NPI number — WILLIAM A MITCHELL JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
WILLIAM
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1194791186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
65 WALNUT ST
Provider Second Line Business Mailing Address:
SUITE 440
Provider Business Mailing Address City Name:
WELLESLEY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02481-2118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-235-9089
Provider Business Mailing Address Fax Number:
781-489-6146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65 WALNUT ST STE 440
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLESLEY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02481-2196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-235-9089
Provider Business Practice Location Address Fax Number:
781-237-5121
Provider Enumeration Date:
02/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  52543 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3007561 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 69218 . This is a "FALLON COMMUN HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2438941 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J03422 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 172421 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: P00271550 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 052543 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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