Basic Information
| Provider Information | |||||||||
| NPI: | 1528051422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUTAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | G | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11125 DUNN RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148395522 | ||||||||
| FaxNumber: | 3148395351 | ||||||||
| Practice Location | |||||||||
| Address1: | 11125 DUNN RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148395522 | ||||||||
| FaxNumber: | 3148395351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036085097 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 101315 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0360850972 | 05 | IL | MEDICAID | 060065494 | 01 | MORRMCR | OTHER | 060065495 | 01 | IL | ILRRMCR | OTHER | 177033 | 01 | HLNK | OTHER | 2500837 | 01 | UHC | OTHER | 4243966 | 01 | AETNA | OTHER | 5386951007 | 01 | CIGNA | OTHER | 12857V3831 | 01 | GHP/CMR | OTHER | 205722705 | 05 | MO | MEDICAID | 34842V8816 | 01 | HCUSA | OTHER | F04428 | 01 | MERCY | OTHER | 149885 | 01 | MO | MOBS/BLCHOICE | OTHER | 98151V30946 | 01 | HLTHPART | OTHER |