Provider Demographics
NPI:1003987173
Name:IDOL R MITCHELL DPM PC
Entity Type:Organization
Organization Name:IDOL R MITCHELL DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IDOL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-836-7900
Mailing Address - Street 1:437 EAST GRANT STREET
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3352
Mailing Address - Country:US
Mailing Address - Phone:309-837-3964
Mailing Address - Fax:309-837-3966
Practice Address - Street 1:437 EAST GRANT STREET
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3352
Practice Address - Country:US
Practice Address - Phone:309-837-3964
Practice Address - Fax:309-837-3966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-12
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004683213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004683Medicaid
480034728OtherRAILROAD MEDICARE
4452210001OtherDMERC
IL214428OtherMEDICARE ID
IL214428OtherMEDICARE ID
480034728OtherRAILROAD MEDICARE
IA12170Medicare ID - Type Unspecified
ILK33206Medicare PIN