Provider Demographics
NPI:1376507103
Name:LANE, FREDERICK ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:ROBERT
Last Name:LANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FREDERICK
Other - Middle Name:ROBERT
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5255 E STOP 11 RD STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6343
Practice Address - Country:US
Practice Address - Phone:317-528-2270
Practice Address - Fax:317-528-2286
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037114A208600000X
IN01037114208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100128830AMedicaid
INE14958Medicare UPIN