Provider Demographics
NPI:1073573465
Name:LANE, MICHAEL W (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:LANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140
Mailing Address - Country:US
Mailing Address - Phone:317-467-4300
Mailing Address - Fax:317-467-4302
Practice Address - Street 1:5035 W. 71ST ST., STE E
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228
Practice Address - Country:US
Practice Address - Phone:317-291-0100
Practice Address - Fax:317-291-2501
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44281174400000X
IN01066599A208100000X
VA0101235883208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAI03940Medicare UPIN