Provider Demographics
NPI:1669639373
Name:PARK ROBERT MITCHELL, M.D.
Entity Type:Organization
Organization Name:PARK ROBERT MITCHELL, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-427-0171
Mailing Address - Street 1:1600 KENNESAW DUE WEST RD NW
Mailing Address - Street 2:STE 620
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4301
Mailing Address - Country:US
Mailing Address - Phone:770-427-0171
Mailing Address - Fax:770-427-2921
Practice Address - Street 1:1600 KENNESAW DUE WEST RD NW
Practice Address - Street 2:STE 620
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4301
Practice Address - Country:US
Practice Address - Phone:770-427-0171
Practice Address - Fax:770-427-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G701048Medicare PIN