Provider Demographics
NPI:1467628073
Name:JERRY M MUTUA MD LLC
Entity Type:Organization
Organization Name:JERRY M MUTUA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MUTUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-994-5502
Mailing Address - Street 1:6810 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1510
Mailing Address - Country:US
Mailing Address - Phone:773-994-5509
Mailing Address - Fax:773-994-7405
Practice Address - Street 1:326 W 64TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3114
Practice Address - Country:US
Practice Address - Phone:773-994-5509
Practice Address - Fax:773-994-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062092Medicaid
ILD14780Medicare UPIN
IL210515Medicare PIN
ILIL1219Medicare PIN