Provider Demographics
NPI:1871526434
Name:RICHARD J. MUTTY MD, PC
Entity type:Organization
Organization Name:RICHARD J. MUTTY MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MUTTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-336-3600
Mailing Address - Street 1:1819 BLACK RIVER BLVD N
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2427
Mailing Address - Country:US
Mailing Address - Phone:315-336-3600
Mailing Address - Fax:315-336-5618
Practice Address - Street 1:1819 BLACK RIVER BLVD N
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2427
Practice Address - Country:US
Practice Address - Phone:315-336-3600
Practice Address - Fax:315-336-5618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123964207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00520663Medicaid
NY00520663Medicaid
NYE86389Medicare UPIN