Basic Information
| Provider Information | |||||||||
| NPI: | 1104815323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | WINSTON | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8600 N STATE ROUTE 91 | ||||||||
| Address2: | STE 250 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616159506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096925393 | ||||||||
| FaxNumber: | 3096922538 | ||||||||
| Practice Location | |||||||||
| Address1: | 2320 E 93RD ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606173909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739672000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01077886A | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 036103962 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207Q00000X | 036103962 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207L00000X | 036103962 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036103962 | 05 | IL | MEDICAID |