Basic Information
| Provider Information | |||||||||
| NPI: | 1679674402 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3315 N SEMINARY ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093441000 | ||||||||
| FaxNumber: | 3093441054 | ||||||||
| Practice Location | |||||||||
| Address1: | 3315 N SEMINARY ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093441000 | ||||||||
| FaxNumber: | 3093441054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| 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 | 208600000X | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 10621858 | 01 | CAQH | OTHER | 4022647 | 01 | AETNA | OTHER | 364271985-38 | 01 | JOHN DEERE | OTHER | 4815127 | 01 | BC/BS | OTHER |