Provider Demographics
NPI:1851380067
Name:MITCHELL, MARILYN L
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 FOXFIELD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1402
Mailing Address - Country:US
Mailing Address - Phone:847-304-5526
Mailing Address - Fax:
Practice Address - Street 1:2075 FOXFIELD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1402
Practice Address - Country:US
Practice Address - Phone:847-304-5526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-063042207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL748450OtherMEDICARE PROVIDER NUMBER
ILP09297Medicare PIN
ILC43195Medicare UPIN