Provider Demographics
NPI:1942236419
Name:MUTCHLER, SCOTT BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:BRADLEY
Last Name:MUTCHLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:BRADLEY
Other - Last Name:MUTCHLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:400 EAST THIRD STREET
Mailing Address - Street 2:MCL2CRED
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-1183
Mailing Address - Fax:
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5699208M00000X, 2080P0203X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269757200Medicaid
MO202065421Medicaid
D26155Medicare UPIN
FL93820XMedicare PIN
D26155Medicare UPIN