Provider Demographics
NPI:1073600979
Name:LEE, LANE M (DO)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:M
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:400 MATTHEW ST STE 401
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1656
Practice Address - Country:US
Practice Address - Phone:740-374-2252
Practice Address - Fax:740-374-4974
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7886208600000X, 2086S0129X
OH34.0051242086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0827289Medicaid
ND10519Medicaid
WV3910000637Medicaid
OHP01297083OtherRAILROAD MEDICARE - MHCPI
NDN21174Medicare PIN
OHP01297083OtherRAILROAD MEDICARE - MHCPI
ND10519Medicaid
E93283Medicare UPIN
WV3910000637Medicaid