Provider Demographics
NPI:1982620530
Name:LANE, PHILIP E (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:E
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 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-0000
Practice Address - Country:US
Practice Address - Phone:770-277-3056
Practice Address - Fax:855-204-5244
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-051264207L00000X
GA070468207L00000X
MDD80354207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137111AMedicaid
IL036-051264Medicaid
ILD14825Medicare UPIN
ILL90790Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER