Provider Demographics
NPI:1295954386
Name:MUTCHNICK, IAN SPENCER (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:SPENCER
Last Name:MUTCHNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:SUITE 1102
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-583-1697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH095567207T00000X
KY43020207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3746249000OtherPASSPORT ADVANTAGE- NORTON NEUROSURGICAL INSTITUTE OF KENTUCKY
KY50026300OtherPASSPORT- NORTON NEUROSURGICAL INSTITUTE OF KENTUCKY
KY200967320OtherANTHEM INDIANA MEDICAID- NORTON NEUROSURGICAL INSTITUTE OF KENTUCKY
IN200967320Medicaid
KY7100090630Medicaid
KY000000642043OtherANTHEM- NORTON NEUROSURGICAL INSTITUTE OF KENTUCKY
KY108520OtherSIHO
KY3810329OtherCIGNA- NORTON NEUROSURGICAL INSTITUTE OF KENTUCKY
KY7100090630Medicaid