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General NPI Number Information
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NPI Number | 1467628073
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Entity Type | Organization
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Legal Business Name | JERRY M MUTUA MD LLC
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Dates
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Enumeration Date | 05/03/2008
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Last Update Date | 04/03/2009
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Provider Practice Location Address
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Address Line | 326 W 64TH ST
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City | CHICAGO
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State | IL
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Zip | 60621-3114
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Country | US
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Telephone | 773-994-5509
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Fax | 773-994-7405
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Provider Business Mailing Address
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Address Line | 6810 S EUCLID AVE
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City | CHICAGO
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State | IL
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Zip | 60649-1510
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Country | US
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Telephone | 773-994-5509
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Fax | 773-994-7405
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. JERRY M MUTUA
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Credential | M.D.
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Telephone | 773-994-5502
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036062092
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License Number State | IL
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