1568461051 NPI number — MITCHELL E NUTT M.D.

Table of content: MITCHELL E NUTT M.D. (NPI 1568461051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568461051 NPI number — MITCHELL E NUTT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUTT
Provider First Name:
MITCHELL
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568461051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 SAINT CLAIR STREET
Provider Second Line Business Mailing Address:
GRAND LAKE PHYSICIAN PRACTICES
Provider Business Mailing Address City Name:
SAINT MARYS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45885-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-394-3387
Provider Business Mailing Address Fax Number:
419-394-7313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1067 HAGER ST
Provider Second Line Business Practice Location Address:
GRAND LAKE OB/GYN
Provider Business Practice Location Address City Name:
SAINT MARYS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45885-2422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-394-3387
Provider Business Practice Location Address Fax Number:
419-394-7313
Provider Enumeration Date:
07/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  35.092080 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0204997 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9934724 . This is a "MEDICARE GROUP PTAN LOCATION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1447288717 . This is a "GROUP NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: NU4097102 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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