Provider Demographics
NPI:1558370361
Name:LANE, KEITH J (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:J
Last Name:LANE
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 1:82 S 1100 E
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1686
Mailing Address - Country:US
Mailing Address - Phone:801-350-4602
Mailing Address - Fax:801-350-4753
Practice Address - Street 1:82 S 1100 E
Practice Address - Street 2:204
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1686
Practice Address - Country:US
Practice Address - Phone:801-350-4602
Practice Address - Fax:801-350-4753
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180506-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E27865Medicare UPIN
UT005569005Medicare PIN