Provider Demographics
NPI:1073722179
Name:LANE, ANTHERECA E (MD)
Entity Type:Individual
Prefix:
First Name:ANTHERECA
Middle Name:E
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANTHERECA
Other - Middle Name:E
Other - Last Name:EDMERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1111 LIGHTHOUSE LANE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-3824
Mailing Address - Country:US
Mailing Address - Phone:574-533-0348
Mailing Address - Fax:574-533-0277
Practice Address - Street 1:1111 LIGHTHOUSE LANE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3824
Practice Address - Country:US
Practice Address - Phone:574-533-0348
Practice Address - Fax:574-533-0277
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063792A207V00000X
TXBP2-0019595207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200867030Medicaid
IN200867030Medicaid