Provider Demographics
NPI:1144425117
Name:OTOLOGIC CENTER, INC.
Entity Type:Organization
Organization Name:OTOLOGIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MARION
Authorized Official - Last Name:LUETJE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-531-7373
Mailing Address - Street 1:3100 BROADWAY ST
Mailing Address - Street 2:SUITE 509
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2658
Mailing Address - Country:US
Mailing Address - Phone:816-531-7373
Mailing Address - Fax:816-531-1404
Practice Address - Street 1:3100 BROADWAY ST
Practice Address - Street 2:SUITE 509
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2658
Practice Address - Country:US
Practice Address - Phone:816-531-7373
Practice Address - Fax:816-531-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO31298207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSX840000Medicare PIN