Provider Demographics
NPI:1972500460
Name:MITCHELL, STEVEN C (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:C
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:209 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1218
Practice Address - Country:US
Practice Address - Phone:618-842-4470
Practice Address - Fax:618-842-3437
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094597Medicaid
IL080105407OtherRAILROAD MEDICARE
IL036094597Medicaid
IL080105407OtherRAILROAD MEDICARE