Provider Demographics
NPI:1194058362
Name:STEPHEN A MITCHELL
Entity type:Organization
Organization Name:STEPHEN A MITCHELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:503-777-1983
Mailing Address - Street 1:5212 SE 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-5629
Mailing Address - Country:US
Mailing Address - Phone:503-777-1983
Mailing Address - Fax:
Practice Address - Street 1:6542 SE LAKE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2138
Practice Address - Country:US
Practice Address - Phone:503-496-4550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MITCHELL PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131742Medicare PIN