Basic Information
Provider Information | |||||||||
NPI: | 1093773459 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MITCHELL | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | BASIL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 234 MEDICAL CIRCLE | ||||||||
Address2: |   | ||||||||
City: | MOREHEAD | ||||||||
State: | KY | ||||||||
PostalCode: | 403511181 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067846641 | ||||||||
FaxNumber: | 6067837281 | ||||||||
Practice Location | |||||||||
Address1: | 234 MEDICAL CIRCLE | ||||||||
Address2: |   | ||||||||
City: | MOREHEAD | ||||||||
State: | KY | ||||||||
PostalCode: | 403511181 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6067846641 | ||||||||
FaxNumber: | 6067802373 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 07/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 26420 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 000023034T | 01 | KY | HUMANA - WS | OTHER | 100706 | 01 | KY | SIHO - WS | OTHER | 3691818000 | 01 | KY | PASSPORT ADVTG - WS | OTHER | 00533088 | 01 | KY | MEDICARE - WS | OTHER | 64264203 | 05 | KY |   | MEDICAID | 50021524 | 01 | KY | PASSPORT - WS | OTHER | 000000601375 | 01 | KY | ANTHEM - WS | OTHER | 200941190 | 05 | IN |   | MEDICAID |