Provider Demographics
NPI:1275718520
Name:ROBERT G MUTCH DO PC
Entity Type:Organization
Organization Name:ROBERT G MUTCH DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:MUTCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:989-635-4023
Mailing Address - Street 1:2750 MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MARLETTE
Mailing Address - State:MI
Mailing Address - Zip Code:48453-1100
Mailing Address - Country:US
Mailing Address - Phone:989-635-4023
Mailing Address - Fax:989-635-5297
Practice Address - Street 1:2750 MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453-1100
Practice Address - Country:US
Practice Address - Phone:989-635-4023
Practice Address - Fax:989-635-5297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013139207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4531773Medicaid
1657615375OtherBCBS PROVIDER NUMBER
MI0N87150Medicare PIN
MI4531773Medicaid