Provider Demographics
NPI:1780660316
Name:STUTMAN, FRED (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:STUTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-632-1400
Mailing Address - Fax:215-632-2176
Practice Address - Street 1:3501 NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19154-2608
Practice Address - Country:US
Practice Address - Phone:215-632-1400
Practice Address - Fax:215-632-2176
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD007124E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000612309Medicaid
PA0047315OtherAETNA HMO
PAP00208191OtherRAILROAD MEDICARE
PA597586OtherMEDICARE GROUP
PA1081468OtherKEYSTONE MERCY HEALTH
PA714OtherBRAVO HEALTH
PA0058304000OtherINDEPENDENCE BLUE CROSS
PA016618OtherHIGHMARK BLUE SHIELD
PA2Y0397OtherHEALTH NET
4076190OtherAETNA PPO
PAP495461OtherOXFORD
PA597586OtherMEDICARE GROUP
PA0047315OtherAETNA HMO