Provider Demographics
NPI:1689603672
Name:LANE, MARIAN (MD)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 532768
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-2768
Mailing Address - Country:US
Mailing Address - Phone:904-805-1300
Mailing Address - Fax:904-805-1302
Practice Address - Street 1:215 MIMS RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-1994
Practice Address - Country:US
Practice Address - Phone:904-805-1300
Practice Address - Fax:904-805-1302
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21262207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA027300OtherBLUE CROSS
GAP00410868OtherRAILROAD MEDICARE
GA93BDHSJMedicare PIN
GAP00410868OtherRAILROAD MEDICARE