Provider Demographics
NPI:1174623664
Name:LUTZ, THOMAS A (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:LUTZ
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 1:1670 CAPITAL ST STE 500
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-8079
Mailing Address - Country:US
Mailing Address - Phone:847-468-9900
Mailing Address - Fax:847-468-9901
Practice Address - Street 1:1670 CAPITAL ST STE 500
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60124
Practice Address - Country:US
Practice Address - Phone:847-468-9900
Practice Address - Fax:847-468-9901
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112147202K00000X, 207R00000X
WI61085-20207R00000X
OH35087011207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00480520OtherMEDICARE RAILROAD PTAN
ILL23712Medicare UPIN
ILP00480520OtherMEDICARE RAILROAD PTAN
WI682270006Medicare PIN
ILK51163Medicare PIN