Provider Demographics
NPI:1972583102
Name:LAINE, EDWARD PAUL (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:PAUL
Last Name:LAINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-1801
Mailing Address - Country:US
Mailing Address - Phone:530-255-1000
Mailing Address - Fax:
Practice Address - Street 1:2036 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1801
Practice Address - Country:US
Practice Address - Phone:530-255-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012103207ZB0001X, 207ZP0102X
KS05-28923207ZP0102X
NE1857207ZP0102X
CA6623207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2152210364OtherBCBSM
MI2152210364OtherBCBSM
MIB26002089Medicare PIN