Provider Demographics
NPI:1821158833
Name:DAVID J. LANE, LTD.
Entity Type:Organization
Organization Name:DAVID J. LANE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:618-242-0672
Mailing Address - Street 1:4117 S WATER TOWER PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6293
Mailing Address - Country:US
Mailing Address - Phone:618-242-0672
Mailing Address - Fax:618-242-0862
Practice Address - Street 1:4117 S WATER TOWER PL
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6293
Practice Address - Country:US
Practice Address - Phone:618-242-0672
Practice Address - Fax:618-242-0862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000854231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL354668512001Medicaid
IL83222520OtherBLUE CROSS BLUE SHIELD