1710113550 NPI number — MATTHEW D MITCHELL CRNA

Table of content: MATTHEW D MITCHELL CRNA (NPI 1710113550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710113550 NPI number — MATTHEW D MITCHELL CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
MATTHEW
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1710113550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
331 NEWMAN SPRINGS RD STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED BANK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07701-5792
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-807-0877
Provider Business Mailing Address Fax Number:
201-751-1680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107-6130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-829-3867
Provider Business Practice Location Address Fax Number:
215-829-5567
Provider Enumeration Date:
06/08/2009

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: 367500000X , with the licence number:  26NJ00363700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: RN573737 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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