Basic Information
Provider Information | |||||||||
NPI: | 1154639508 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANE | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | LEE SEROWKA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SEROWKA LANE | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 101 W UNIVERSITY AVE | ||||||||
Address2: |   | ||||||||
City: | CHAMPAIGN | ||||||||
State: | IL | ||||||||
PostalCode: | 618203981 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2173661248 | ||||||||
FaxNumber: | 2173666100 | ||||||||
Practice Location | |||||||||
Address1: | 101 W UNIVERSITY AVE | ||||||||
Address2: |   | ||||||||
City: | CHAMPAIGN | ||||||||
State: | IL | ||||||||
PostalCode: | 618203981 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2173661248 | ||||||||
FaxNumber: | 2173666100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2010 | ||||||||
LastUpdateDate: | 03/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 036154202 | IL | Y |   | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 036154202 | IL | N |   | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.