Basic Information
| Provider Information | |||||||||
| NPI: | 1578522330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 MOPAC EXPRESSWAY NORTH | ||||||||
| Address2: | NORTH AUSTIN MEDICAL CENTER | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129012500 | ||||||||
| FaxNumber: | 5129011998 | ||||||||
| Practice Location | |||||||||
| Address1: | 6101 BALCONES DR | ||||||||
| Address2: | SUITE #300 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787314231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124820045 | ||||||||
| FaxNumber: | 5124769892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | H0645 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 123748903 | 05 | TX | MEDICAID |