Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RC0000X | Internist - Cardiovascular Disease | 02003221A | IN |
Y | 207RC0001X | Clinical Cardiac Electrophysiologist | 02003221A | IN |
N | 207RC0001X | Clinical Cardiac Electrophysiologist | 036-108244 | IL |
N | 207RC0001X | Clinical Cardiac Electrophysiologist | 036.108244 | IL |
NPI | 1265552756 |
---|---|
Provider Name | Dr. Mark A Mitchell |
First Address | Detroit, MI 48278-1076 |
Second Address | Dyer, IN 46311 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2007 |
Last Update Date | 15/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200911930 | (05) | IN |
E97193 | (02) |