Provider Demographics
NPI:1669475307
Name:MITCHELL, GREGORY ALAN (MD, PA)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 BESTGATE RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-2953
Mailing Address - Country:US
Mailing Address - Phone:410-266-8601
Mailing Address - Fax:410-266-7268
Practice Address - Street 1:888 BESTGATE ROAD
Practice Address - Street 2:SUITE 211
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-2953
Practice Address - Country:US
Practice Address - Phone:410-266-8601
Practice Address - Fax:410-266-7268
Is Sole Proprietor?:No
Enumeration Date:2005-05-26
Last Update Date:2008-10-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
MDD0014758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD250541000Medicaid
MD250541000Medicaid
319MMedicare PIN