Basic Information
| Provider Information | |||||||||
| NPI: | 1467972653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ORTONVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562781357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208394090 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 6TH ST NE | ||||||||
| Address2: | |||||||||
| City: | CHISHOLM | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557191287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182747712 | ||||||||
| FaxNumber: | 2182549968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2017 | ||||||||
| LastUpdateDate: | 06/20/2017 | ||||||||
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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 | 225100000X | 1969 | ND | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1969 | 01 | ND | STATE LICENSE FOR PT | OTHER |