Provider Demographics
NPI:1669498887
Name:MUTCH, MATTHEW G (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:G
Last Name:MUTCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-7177
Mailing Address - Fax:888-425-7946
Practice Address - Street 1:1044 N MASON RD
Practice Address - Street 2:DIV SURG COLON/RECTAL, STE 310
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6431
Practice Address - Country:US
Practice Address - Phone:314-454-7177
Practice Address - Fax:888-425-7946
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106142208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205822604Medicaid
ILENROLLEDMedicaid
MO280001097Medicare PIN
MO107010181Medicaid