Basic Information
| Provider Information | |||||||||
| NPI: | 1295028546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | KOREY | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1680 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257171680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046971396 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 WAYNE ST | ||||||||
| Address2: | |||||||||
| City: | FORT GAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255148518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046485544 | ||||||||
| FaxNumber: | 3046485989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2011 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 25693 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100303880 | 05 | KY | MEDICAID | 0104755 | 05 | OH | MEDICAID | 3810027586 | 05 | WV | MEDICAID |