Healthcare Provider Details

I. General information

NPI: 1891893491
Provider Name (Legal Business Name): MUTENA B. KORMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 HARRISON ST STE 380
MERRILLVILLE IN
46410-2972
US

IV. Provider business mailing address

2010 N HARLEM AVE
ELMWOOD PARK IL
60707-3119
US

V. Phone/Fax

Practice location:
  • Phone: 219-942-4222
  • Fax: 219-942-4233
Mailing address:
  • Phone: 708-452-1111
  • Fax: 708-452-4593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01055605A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: