Provider Demographics
NPI:1255409702
Name:MITCHELL, LAWRENCE C (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:C
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2520 S TELEGRAPH ROAD
Mailing Address - Street 2:HENRY FORD HEALTH SYSTEM
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48330
Mailing Address - Country:US
Mailing Address - Phone:248-451-6001
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:6777 WEST MAPLE ROAD
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323
Practice Address - Country:US
Practice Address - Phone:248-661-6450
Practice Address - Fax:248-661-6649
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI039076207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
700H262220OtherBLUE CROSS-BLUE CROSS
LM039076OtherCOMMERCIAL-COMMERCIAL NUMBER
MI137335810Medicaid
LM039076OtherCHAMPUS-CHAMPUS
700H262220OtherBLUE CROSS-BLUE CROSS
LM039076OtherCOMMERCIAL-COMMERCIAL NUMBER