Provider Demographics
NPI:1487121612
Name:MITCHELL, BENJAMIN C
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S RAVENEL ST STE 270
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2624
Mailing Address - Country:US
Mailing Address - Phone:843-777-7020
Mailing Address - Fax:843-664-9545
Practice Address - Street 1:101 S RAVENEL ST STE 270
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2624
Practice Address - Country:US
Practice Address - Phone:843-777-7020
Practice Address - Fax:843-664-9545
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant