Basic Information
| Provider Information | |||||||||
| NPI: | 1881686749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29870 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850389870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027723800 | ||||||||
| FaxNumber: | 6027723801 | ||||||||
| Practice Location | |||||||||
| Address1: | 8630 E VIA DE VENTURA STE 201 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852583358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805583744 | ||||||||
| FaxNumber: | 4805583801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 07/30/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/23/2006 | ||||||||
| NPIReactivationDate: | 03/29/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 27147 | AZ | N | Other Service Providers | Specialist | 207X00000X | 27147 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | Z149329 | 01 | AZ | PTAN | OTHER | 450007 | 05 | AZ | MEDICAID |