Provider Demographics
NPI:1215014279
Name:MCNUTT, RICHARD KEVIN (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:KEVIN
Last Name:MCNUTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13508
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-3508
Mailing Address - Country:US
Mailing Address - Phone:920-965-7411
Mailing Address - Fax:920-965-7412
Practice Address - Street 1:900 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3508
Practice Address - Country:US
Practice Address - Phone:920-965-7411
Practice Address - Fax:920-965-7412
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27731208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31707700Medicaid
WI31707700Medicaid
WI000107850Medicare ID - Type Unspecified