Basic Information
Provider Information | |||||||||
NPI: | 1235284415 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRIAN C. DE MUTH M.D., PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHESAPEAKE SPORTS & ORTHOPAEDICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 251 LEWIS LN | ||||||||
Address2: | SUITE 103 | ||||||||
City: | HAVRE DE GRACE | ||||||||
State: | MD | ||||||||
PostalCode: | 210783751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109393400 | ||||||||
FaxNumber: | 4109396400 | ||||||||
Practice Location | |||||||||
Address1: | 251 LEWIS LN | ||||||||
Address2: | SUITE103 | ||||||||
City: | HAVRE DE GRACE | ||||||||
State: | MD | ||||||||
PostalCode: | 210783751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109393400 | ||||||||
FaxNumber: | 4109396400 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2007 | ||||||||
LastUpdateDate: | 05/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DE MUTH | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | CHARLES | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 4109393400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | D50790 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 522110201 | 05 | MD |   | MEDICAID |