Provider Demographics
NPI:1710024716
Name:RONALD LUETHKE MD PA
Entity Type:Organization
Organization Name:RONALD LUETHKE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LUETHKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-964-8287
Mailing Address - Street 1:10710 CHARTER DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3128
Mailing Address - Country:US
Mailing Address - Phone:410-964-8287
Mailing Address - Fax:410-964-2761
Practice Address - Street 1:10710 CHARTER DR
Practice Address - Street 2:SUITE 240
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3128
Practice Address - Country:US
Practice Address - Phone:410-964-8287
Practice Address - Fax:410-964-2761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00368622086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD531561100Medicaid
MDE28711Medicare UPIN