Provider Demographics
NPI:1245344043
Name:LANE, SALLY D (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:D
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 RIDGE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1745
Mailing Address - Country:US
Mailing Address - Phone:215-487-3070
Mailing Address - Fax:215-487-2362
Practice Address - Street 1:5735 RIDGE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1745
Practice Address - Country:US
Practice Address - Phone:215-487-3070
Practice Address - Fax:215-487-2362
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD17324E207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC31958Medicare UPIN