Provider Demographics
NPI:1831158971
Name:LANE, JEROME CHARLES (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:CHARLES
Last Name:LANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:520 WEST HURON STREET
Mailing Address - Street 2:APT #603
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610
Mailing Address - Country:US
Mailing Address - Phone:312-280-8083
Mailing Address - Fax:
Practice Address - Street 1:2300 CHILDRENS PLAZA
Practice Address - Street 2:BOX #37, CHILDRENS MEMORIAL HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-327-3930
Practice Address - Fax:773-327-3939
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H31764Medicare UPIN
ILL84063Medicare ID - Type Unspecified