Provider Demographics
NPI:1689705485
Name:GERALD W. LANE, INC.
Entity Type:Organization
Organization Name:GERALD W. LANE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-447-7898
Mailing Address - Street 1:6530 BRODIE BLVD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-8009
Mailing Address - Country:US
Mailing Address - Phone:614-946-3588
Mailing Address - Fax:
Practice Address - Street 1:6530 BRODIE BLVD.
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017
Practice Address - Country:US
Practice Address - Phone:614-447-7898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-4829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0752672Medicaid
OH0752672Medicaid