Daugherty, Mitchell
Daugherty, Mitchell is an individual health care provider with primary practice located at 111 W Jefferson Blvd Ste 100 , South Bend IN 46601-1993. He recently has 2 registered licenses in different health care specialties including Allopathic & Osteopathic Physicians / Sports Medicine, Allopathic & Osteopathic Physicians / Family Medicine. Allopathic & Osteopathic Physicians / Family Medicine is his primary health care specialty. Daugherty, Mitchell can be contacted via phone (574) 647-1670.Contact Information
Primary practice address
111 W Jefferson Blvd Ste 100
South Bend IN 46601-1993
Phone: (574) 647-1670
Fax: (574) 647-6927
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Sports Medicine | 207QS0010X | 01082368A | Indiana |
| Allopathic & Osteopathic Physicians / Family Medicine | 207Q00000X | 01082368A | Indiana |
Profile Details
| NPI number | 1417481540 |
|---|---|
| LBN Legal business name | Daugherty, Mitchell |
| Credentials | |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Apr 14th, 2017 |
| Last updated | Aug 19th, 2022 - about 2 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1417481540 | NPPES |
| Indiana | Other | 236040377 | MEDICARE PTAN |
| Indiana | Other | 261970152 | MEDICARE PTAN |
| Indiana | MEDICAID | 300003172 | MEDICARE PTAN |
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