Basic Information
| Provider Information | |||||||||
| NPI: | 1740369578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE MUTH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W HIGH ST | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219215529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106206300 | ||||||||
| FaxNumber: | 4106206377 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W HIGH ST | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219215529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106206300 | ||||||||
| FaxNumber: | 4106206377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | D50790 | MD | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 522110201 | 05 | MD | MEDICAID |