Basic Information
| Provider Information | |||||||||
| NPI: | 1831356898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 75 BAYLOR DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435405857 | ||||||||
| FaxNumber: | 8435245655 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 BAYLOR DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435405857 | ||||||||
| FaxNumber: | 8435245655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | TL30744 | SC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 307448 | 05 | SC | MEDICAID |