Provider Demographics
NPI:1790722544
Name:LANE, TIMOTHY WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WALTER
Last Name:LANE
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 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:336-832-7000
Mailing Address - Fax:
Practice Address - Street 1:301 E WENDOVER AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1230
Practice Address - Country:US
Practice Address - Phone:336-832-7840
Practice Address - Fax:336-832-3285
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22588207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC26776OtherMEDCOST
NC50794OtherBCBS NC
NC3595OtherPARTNERS MEDICARE CHOICE
NC8950794Medicaid
NC4316181OtherAETNA
NC4316181OtherAETNA
NC3595OtherPARTNERS MEDICARE CHOICE