Provider Demographics
NPI:1598723900
Name:MOORE, LANE INGRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:LANE
Middle Name:INGRAM
Last Name:MOORE
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 1:845 82ND PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4614
Mailing Address - Country:US
Mailing Address - Phone:843-449-9621
Mailing Address - Fax:
Practice Address - Street 1:845 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4614
Practice Address - Country:US
Practice Address - Phone:843-449-9621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22109208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC221094Medicaid
67728OtherMEDCOST
NC89063Y4Medicaid
SC221094Medicaid