1184059784 NPI number — TIM MITCHELL MEDICAL, INC

Table of content: (NPI 1184059784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184059784 NPI number — TIM MITCHELL MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIM MITCHELL MEDICAL, 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:
6
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:
1184059784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
719 S NEOSHO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEOSHO
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64850-2051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-455-1883
Provider Business Mailing Address Fax Number:
417-455-2781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 E HICKORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEOSHO
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64850-1806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-451-3776
Provider Business Practice Location Address Fax Number:
417-451-2332
Provider Enumeration Date:
09/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
417-451-3776

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 600003470 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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