Basic Information
| Provider Information | |||||||||
| NPI: | 1073600979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | LANE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MATTHEW ST STE 401 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403742252 | ||||||||
| FaxNumber: | 7403744974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 7886 | ND | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 7886 | ND | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 34.005124 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0827289 | 05 | OH | MEDICAID | 10519 | 05 | ND | MEDICAID | 3910000637 | 05 | WV | MEDICAID | P01297083 | 01 | OH | RAILROAD MEDICARE - MHCPI | OTHER |