Provider Demographics
NPI:1912152679
Name:MITCHELL HARDISON, M.D., PLLC
Entity Type:Organization
Organization Name:MITCHELL HARDISON, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-418-9002
Mailing Address - Street 1:2301 REXWOODS DR
Mailing Address - Street 2:SUITE 118, REXWOODS III
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-3366
Mailing Address - Country:US
Mailing Address - Phone:919-803-1417
Mailing Address - Fax:919-803-1418
Practice Address - Street 1:2301 REXWOODS DR
Practice Address - Street 2:SUITE 118, REXWOODS III
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3366
Practice Address - Country:US
Practice Address - Phone:919-803-1417
Practice Address - Fax:919-803-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26442207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC26442OtherDEA# AH1719511
C84322Medicare UPIN