Provider Demographics
NPI:1093907982
Name:MUTCH, AMY E (CRNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:MUTCH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 RESEARCH PARK DR FL 4
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4873
Mailing Address - Country:US
Mailing Address - Phone:410-247-5602
Mailing Address - Fax:410-242-1756
Practice Address - Street 1:711 MAIDEN CHOICE LN
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-3632
Practice Address - Country:US
Practice Address - Phone:410-242-5602
Practice Address - Fax:410-242-1756
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR095947207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419000900Medicaid
KG01ER-686115-01OtherCAREFIRST BCBS OF MD
0024OtherBCBS OF DC
MD960702100Medicaid
8300978OtherEVERCARE
686115-01OtherBCBS OF MD
590L988CMedicare PIN
500007177Medicare PIN
8300978OtherEVERCARE