Provider Demographics
NPI:1639191190
Name:RAUCH, MITCHELL K (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:K
Last Name:RAUCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CLINIC AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4402
Mailing Address - Country:US
Mailing Address - Phone:678-390-7164
Mailing Address - Fax:
Practice Address - Street 1:670 GLADES ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431
Practice Address - Country:US
Practice Address - Phone:561-391-6470
Practice Address - Fax:561-394-2306
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068700208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253485100Medicaid
FL42722OtherBCBS
FL1453279OtherCIGNA
FL259384OtherAVMED
FLP01606320OtherRR MEDICARE
FL0E640OtherWELLCARE
FLP1035782OtherFREEDOM
FLP971547OtherOPTIMUM
FL4386OtherDIMENSION HEALTH
FL5682670OtherAETNA
FL1453279OtherCIGNA
FL5682670OtherAETNA
FL42722Medicare PIN