Basic Information
| Provider Information | |||||||||
| NPI: | 1073624953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTZ | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18139 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276198139 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843034 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 187212 | 01 | NC | MEDCOST | OTHER | 89138H1 | 05 | NC | MEDICAID | P00363054 | 01 | NC | RAILRAOD-MEDICARE | OTHER | 138H1 | 01 | NC | BCBS NC | OTHER | 4579748 | 01 | NC | CIGNA | OTHER | 807329 | 01 | NC | PARTNERS | OTHER |