Provider Demographics
NPI:1629065909
Name:LANE, GLENN D (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:D
Last Name:LANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:G.
Other - Middle Name:DALE
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1285 HEMBREE RD
Mailing Address - Street 2:SUITE 200-A
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5720
Mailing Address - Country:US
Mailing Address - Phone:770-475-2710
Mailing Address - Fax:770-360-0498
Practice Address - Street 1:1285 HEMBREE RD
Practice Address - Street 2:SUITE 200-A
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5720
Practice Address - Country:US
Practice Address - Phone:770-475-2710
Practice Address - Fax:770-360-0498
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025204207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20BBDPTMedicare PIN
GAD50909Medicare UPIN