Provider Demographics
NPI:1205886124
Name:MITCHELL, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 DOUGHTY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5727
Mailing Address - Country:US
Mailing Address - Phone:843-577-6791
Mailing Address - Fax:
Practice Address - Street 1:125 DOUGHTY ST STE 200
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5727
Practice Address - Country:US
Practice Address - Phone:843-577-6791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17744207RC0200X, 207RP1001X
NC2015-00244207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC177445Medicaid
SC284442300OtherOWCP-WC #
NC1205886124Medicaid
SCP00941904OtherRAILROAD MC ID - RHI
SC290007245OtherRR MEDICARE #
SCF596405551Medicare PIN
NC1205886124Medicaid
NCNCM655AMedicare PIN
SCF596404550Medicare PIN