Basic Information
| Provider Information | |||||||||
| NPI: | 1114003746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL W LANE MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3556 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238053556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046416741 | ||||||||
| FaxNumber: | 8048610050 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 PINEHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238059233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046416741 | ||||||||
| FaxNumber: | 8048610050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | LANE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8046416741 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | VA | MEDICAID |