Provider Demographics
NPI:1508839895
Name:MITCHELL, PHILIP W (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:W
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1422
Mailing Address - Country:US
Mailing Address - Phone:309-452-8404
Mailing Address - Fax:
Practice Address - Street 1:1404 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1422
Practice Address - Country:US
Practice Address - Phone:309-452-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-070228207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44919Medicare UPIN