1801865316 NPI number — DR. KENNETH STEPHEN LUTTER MD

Table of content: DR. KENNETH STEPHEN LUTTER MD (NPI 1801865316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801865316 NPI number — DR. KENNETH STEPHEN LUTTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUTTER
Provider First Name:
KENNETH
Provider Middle Name:
STEPHEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801865316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 NORTH MAYFAIR ROAD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-2252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-258-9511
Provider Business Mailing Address Fax Number:
414-607-3948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
941 CHATHAM LANE
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43221-2416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-457-5191
Provider Business Practice Location Address Fax Number:
614-459-6874
Provider Enumeration Date:
03/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  35-05-4308 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0797688 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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