Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 1385400 | IL |
Y | 213ES0000X | Sports Medicine | 1385400 | IL |
N | 2081S0010X | Sports Medicine | 1385401 | IL |
N | 213ES0000X | Sports Medicine | 1385401 | IL |
NPI | 1447910682 |
---|---|
Provider Name | Jeremiah Mitchell |
First Address | Matteson, IL 60443-1769 |
Second Address | Matteson, IL 60443-1825 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2021 |
Last Update Date | 29/12/2021 |