Provider Demographics
NPI:1578676078
Name:MITCHUM MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:MITCHUM MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MITCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-684-9400
Mailing Address - Street 1:100 W LAKE PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:AL
Mailing Address - Zip Code:36340-1203
Mailing Address - Country:US
Mailing Address - Phone:334-684-9400
Mailing Address - Fax:334-684-6262
Practice Address - Street 1:100 W LAKE PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:AL
Practice Address - Zip Code:36340-1203
Practice Address - Country:US
Practice Address - Phone:334-684-9400
Practice Address - Fax:334-684-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC70252Medicare UPIN