Provider Demographics
NPI:1164581468
Name:LANE, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:LANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6810 STATE ROUTE 162 STE 100
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8560
Mailing Address - Country:US
Mailing Address - Phone:618-288-3616
Mailing Address - Fax:618-288-3647
Practice Address - Street 1:6810 STATE ROUTE 162 STE 100
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8560
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:618-288-3647
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2020-03-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036083769208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL353524701001Medicaid
IL353524701001Medicaid