Provider Demographics
NPI:1669418042
Name:TIM MITCHELL MEDICAL INC
Entity type:Organization
Organization Name:TIM MITCHELL MEDICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-451-9501
Mailing Address - Street 1:1009 S NEOSHO BLVD
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-2008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1009 S NEOSHO BLVD
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-2008
Practice Address - Country:US
Practice Address - Phone:417-455-1882
Practice Address - Fax:417-455-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005032630332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2636453OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2636453OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO000045182Medicare PIN