Provider Demographics
NPI:1235284415
Name:BRIAN C. DE MUTH M.D., PA
Entity Type:Organization
Organization Name:BRIAN C. DE MUTH M.D., PA
Other - Org Name:CHESAPEAKE SPORTS & ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DE MUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-939-3400
Mailing Address - Street 1:251 LEWIS LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3751
Mailing Address - Country:US
Mailing Address - Phone:410-939-3400
Mailing Address - Fax:410-939-6400
Practice Address - Street 1:251 LEWIS LN
Practice Address - Street 2:SUITE103
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3751
Practice Address - Country:US
Practice Address - Phone:410-939-3400
Practice Address - Fax:410-939-6400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD50790207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD522110201Medicaid
MD522110201Medicaid
MD060MMedicare PIN
MDG31808Medicare UPIN