Provider Demographics
NPI:1396787321
Name:LANE, KELLIE V (MD)
Entity type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:V
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 1:4354 DEERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4604
Mailing Address - Country:US
Mailing Address - Phone:706-210-1449
Mailing Address - Fax:
Practice Address - Street 1:818 SAINT SEBASTIAN WAY
Practice Address - Street 2:SUITE 311
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2651
Practice Address - Country:US
Practice Address - Phone:706-724-3473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043233207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG45205Medicare UPIN
GA06BDJDLMedicare ID - Type Unspecified