Provider Demographics
NPI:1952478430
Name:GENERAL AND VASCULAR SURGICAL ASSOC
Entity Type:Organization
Organization Name:GENERAL AND VASCULAR SURGICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-3616
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-288-3616
Mailing Address - Fax:618-288-3647
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 105
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-3616
Practice Address - Fax:618-288-3647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty