Healthcare Provider Details

I. General information

NPI: 1669498887
Provider Name (Legal Business Name): MATTHEW G MUTCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 N MASON RD DIV SURG COLON/RECTAL, STE 310
SAINT LOUIS MO
63141-6431
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-7177
  • Fax: 888-425-7946
Mailing address:
  • Phone: 314-454-7177
  • Fax: 888-425-7946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number106142
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number106142
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: