Provider Demographics
NPI:1649220443
Name:CHARLOTTE RADIOLOGY PA
Entity Type:Organization
Organization Name:CHARLOTTE RADIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER PAYER ENROLLMENT & AUDIT SP
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-334-7800
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 1:700 E MOREHEAD ST STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202
Practice Address - Country:US
Practice Address - Phone:704-362-5391
Practice Address - Fax:704-414-7512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC336176Medicaid
NCCE8301OtherRR MEDICARE (GROUP)
NC7901111Medicaid
SC336176Medicaid
NC204236Medicare PIN