Provider Demographics
NPI:1003110677
Name:CHARLOTTE RADIOLOGY PA
Entity Type:Organization
Organization Name:CHARLOTTE RADIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER PAYER PRIVILEGING
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:T
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-362-5391
Mailing Address - Street 1:700 E MOREHEAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2742
Mailing Address - Country:US
Mailing Address - Phone:704-334-7800
Mailing Address - Fax:704-414-7512
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR STE 150
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2973
Practice Address - Country:US
Practice Address - Phone:704-362-5391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00921619OtherRR MEDICARE
NC5916456Medicaid
NC5916456Medicaid