Provider Demographics
NPI:1700105970
Name:MUTH, CHRISTOPHER CARL (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:CARL
Last Name:MUTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 1106
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3845
Mailing Address - Country:US
Mailing Address - Phone:312-942-4500
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 1106
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3845
Practice Address - Country:US
Practice Address - Phone:312-942-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125:057571207R00000X
IL036-1438942084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201311130Medicaid
IN201311130Medicaid