Provider Demographics
NPI:1366440356
Name:DILLMAN, MITCHELL FOY (M D)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:FOY
Last Name:DILLMAN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-2286
Mailing Address - Fax:
Practice Address - Street 1:11082 N RADIO STATION RD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-1142
Practice Address - Country:US
Practice Address - Phone:864-882-2314
Practice Address - Fax:864-882-3677
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4697Medicaid
SCTL5943Medicaid
SC080028018OtherRAILROAD MEDICARE
SCE12709Medicare UPIN
SCE127091259Medicare ID - Type Unspecified
SCTL5943Medicaid