1235284415 NPI number — BRIAN C. DE MUTH M.D., PA

Table of content: (NPI 1235284415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235284415 NPI number — BRIAN C. DE MUTH M.D., PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN C. DE MUTH M.D., PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1235284415
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 LEWIS LN
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
HAVRE DE GRACE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21078-3751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-939-3400
Provider Business Mailing Address Fax Number:
410-939-6400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 LEWIS LN
Provider Second Line Business Practice Location Address:
SUITE103
Provider Business Practice Location Address City Name:
HAVRE DE GRACE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21078-3751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-939-3400
Provider Business Practice Location Address Fax Number:
410-939-6400
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DE MUTH
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
410-939-3400

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  D50790 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 522110201 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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