Basic Information
| Provider Information | |||||||||
| NPI: | 1801818927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUTHU | ||||||||
| FirstName: | AMRUTHAVALLI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2129 STATESVILLE BLVD | ||||||||
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| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281471411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046333616 | ||||||||
| FaxNumber: | 7046368818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 02/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 9700111 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8911304 | 05 | NC | MEDICAID |