MEDICARE: MITCHELL E NUTT 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	207V00000X	Obstetrics & Gynecology Physician	35.092080	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	9934724	OTHER	OH	MEDICARE GROUP PTAN LOCATION
4	NU4097102	OTHER	OH	MEDICARE PTAN

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
3	1447288717	OTHER	OH	GROUP NPI

General Provider Information

NPI Number	:	1568461051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL E NUTT M.D.

Provider Business Mailing Address
First Line	:	200 SAINT CLAIR STREET
Second Line	:	GRAND LAKE PHYSICIAN PRACTICES
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2400
Country	:	US
Telephone Number	:	419-394-3387
Fax Number	:	419-394-7313

Provider Business Practice Location Address
First Line	:	1067 HAGER ST
Second Line	:	GRAND LAKE OB/GYN
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2422
Country	:	US
Telephone Number	:	419-394-3387
Fax Number	:	419-394-7313

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	01/02/2014

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Directions to “ MITCHELL E NUTT M.D.” Practice Location

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