Provider Demographics
NPI:1265453112
Name:LAGE, JANICE (MD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:LAGE
Suffix:
Gender:F
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:PO BOX 11407
Mailing Address - Street 2:DEPT #2130
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2130
Mailing Address - Country:US
Mailing Address - Phone:601-925-6805
Mailing Address - Fax:601-926-4971
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6426
Practice Address - Fax:601-984-6439
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21379207ZP0102X
MS22481207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT55696Medicaid
MS08129845Medicaid
SCB99069Medicare UPIN
SCT55696Medicaid