Provider Demographics
NPI:1245486919
Name:JOSHARON MUTCHLER, MD, PLLC
Entity type:Organization
Organization Name:JOSHARON MUTCHLER, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SWISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-235-2090
Mailing Address - Street 1:PO BOX 120125
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49528-0103
Mailing Address - Country:US
Mailing Address - Phone:616-235-2090
Mailing Address - Fax:616-235-2099
Practice Address - Street 1:2035 28TH ST SE
Practice Address - Street 2:SUITE P
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-1594
Practice Address - Country:US
Practice Address - Phone:616-245-2464
Practice Address - Fax:616-452-0728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010807822084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty