Basic Information
| Provider Information | |||||||||
| NPI: | 1912152679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MITCHELL HARDISON, M.D., PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 REXWOODS DR | ||||||||
| Address2: | SUITE 118, REXWOODS III | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276073366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198031417 | ||||||||
| FaxNumber: | 9198031418 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 REXWOODS DR | ||||||||
| Address2: | SUITE 118, REXWOODS III | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276073366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198031417 | ||||||||
| FaxNumber: | 9198031418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2008 | ||||||||
| LastUpdateDate: | 11/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARDISON | ||||||||
| AuthorizedOfficialFirstName: | MARIANNE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9194189002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 26442 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 26442 | 01 | NC | DEA# AH1719511 | OTHER |