Provider Demographics
NPI:1669410627
Name:MITCHELL CLINIC LTD
Entity type:Organization
Organization Name:MITCHELL CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KUMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-996-7526
Mailing Address - Street 1:818 W HAVENS
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-3830
Mailing Address - Country:US
Mailing Address - Phone:605-996-7526
Mailing Address - Fax:605-996-1808
Practice Address - Street 1:818 W HAVENS ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-3830
Practice Address - Country:US
Practice Address - Phone:605-996-7526
Practice Address - Fax:605-996-1808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0275900001Medicare NSC
SDS78Medicare PIN