MEDICARE: DR. RICHARD JOHN MUTTY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	123964-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487658407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD JOHN MUTTY M.D.

Provider Business Mailing Address
First Line	:	1819 BLACK RIVER BLVD N
Second Line	:
City	:	ROME
State	:	NY
Zip	:	13440-2427
Country	:	US
Telephone Number	:	315-336-5600
Fax Number	:	315-336-5618

Provider Business Practice Location Address
First Line	:	1819 BLACK RIVER BLVD N
Second Line	:
City	:	ROME
State	:	NY
Zip	:	13440-2427
Country	:	US
Telephone Number	:	315-336-5600
Fax Number	:	315-336-5618

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	01/28/2010

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