Provider Demographics
NPI:1407299894
Name:DR. DALE MITCHUM INC.
Entity Type:Organization
Organization Name:DR. DALE MITCHUM INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MITCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-684-3007
Mailing Address - Street 1:PO BOX 900
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:AL
Mailing Address - Zip Code:36340-0900
Mailing Address - Country:US
Mailing Address - Phone:334-684-3007
Mailing Address - Fax:334-684-3059
Practice Address - Street 1:100 W LAKE PROFESSIONAL PARK STE 2
Practice Address - Street 2:GENEVA
Practice Address - City:GENEVA
Practice Address - State:AL
Practice Address - Zip Code:36340-1200
Practice Address - Country:US
Practice Address - Phone:334-684-3007
Practice Address - Fax:334-684-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12381207Q00000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty