Basic Information
| Provider Information | |||||||||
| NPI: | 1619939774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 N. BELT HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | ST. JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645062410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162717077 | ||||||||
| FaxNumber: | 8162710421 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 N. BELT HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | ST. JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645062410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162717077 | ||||||||
| FaxNumber: | 8162710421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 11/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | RIF70 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619939774 | 05 | MO | MEDICAID | 200743250A | 05 | KS | MEDICAID |