Provider Demographics
NPI:1467533166
Name:BEATTY, LANE THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:THOMAS
Last Name:BEATTY
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 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-4618
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD22897208M00000X
NH11344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1966421OtherCIGNA
ME317530099Medicaid
NH5375057OtherCCN
NH2030699OtherMAIL HANDLERS/FIRST HEALT
NH30201572Medicaid
NH7775483OtherAETNA
NH781771OtherCIGNA NATIONAL
NHAA21070OtherHARVARD PILGRIM
NH4146689OtherMVP HEALTHCARE
NHP00170892OtherRAIL ROAD MEDICARE
NHAA21070OtherHARVARD PILGRIM
NH30201572Medicaid