Provider Demographics
NPI:1740227032
Name:LANE, GEORGE W SR (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:LANE
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-6644
Mailing Address - Fax:309-692-8992
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-6644
Practice Address - Fax:309-692-8992
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03064025207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148547OtherHEALTHLINK
IL4281670001OtherDME
IL200041572OtherRR MEDICARE
IL7230175OtherBLUE CROSS BLUE SHIELD
IL036064025Medicaid
ILIL0102OtherJOHN DEERE
IL050053OtherHEALTH ALLIANCE
IL4281670001OtherDME
IL200041572OtherRR MEDICARE
IL036064025Medicaid