Provider Demographics
NPI:1134186760
Name:LANE, CHARLES J (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
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:PO BOX 2080
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-2080
Mailing Address - Country:US
Mailing Address - Phone:804-435-3508
Mailing Address - Fax:
Practice Address - Street 1:180 FLOYD AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1318
Practice Address - Country:US
Practice Address - Phone:540-483-5277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054874207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005878365Medicaid
VA005878357Medicaid
F02288Medicare UPIN
VA930125413Medicare ID - Type UnspecifiedRROAD GRP CH9491
000226C51Medicare PIN