1609808781 NPI number — DR. RANDALL E MITCHEM D.O.

Table of content: DR. RANDALL E MITCHEM D.O. (NPI 1609808781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609808781 NPI number — DR. RANDALL E MITCHEM D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHEM
Provider First Name:
RANDALL
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609808781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5301 FARAON ST STE 210A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64506-3512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-271-1385
Provider Business Mailing Address Fax Number:
816-271-1379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5301 FARAON ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64506-3373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-271-1385
Provider Business Practice Location Address Fax Number:
816-271-1379
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  R6J49 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: R6J49 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: R6J49 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 205865009 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2104655 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 100233020B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 403991 . This is a "BLUE CROSS BLUE SHIELD KS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 10001363800 . This is a "CHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 25862028 . This is a "BLUE CROSS BLUE SHIELD KC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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