1467895615 NPI number — MR. JONATHAN CHARLES MITCHELL BHRS

Table of content: MR. JONATHAN CHARLES MITCHELL BHRS (NPI 1467895615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467895615 NPI number — MR. JONATHAN CHARLES MITCHELL BHRS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
JONATHAN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BHRS
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:
1467895615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 112
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73730-0112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-747-0957
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1625 W GARRIOTT RD
Provider Second Line Business Practice Location Address:
ST F
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73703-5653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-242-4673
Provider Business Practice Location Address Fax Number:
580-242-4679
Provider Enumeration Date:
04/08/2013

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: 104100000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200081240 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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