Basic Information
| Provider Information | |||||||||
| NPI: | 1770781288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 HIGHLAND BLVD | ||||||||
| Address2: | ATTN PFS CREDENTIALING | ||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597156902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064145000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 334 TOWN CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | BIG SKY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597161713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4069956995 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MR-0929 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 12374 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1770781288 | 05 | MT | MEDICAID | 807773400 | 05 | ID | MEDICAID |