1639154834 NPI number — ROGER B LANE JR. M.D.

Table of content: ROGER B LANE JR. M.D. (NPI 1639154834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639154834 NPI number — ROGER B LANE JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANE
Provider First Name:
ROGER
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639154834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29417-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-554-9300
Provider Business Mailing Address Fax Number:
843-566-8780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3011 HAMPTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-4264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-261-2669
Provider Business Practice Location Address Fax Number:
912-261-0561
Provider Enumeration Date:
12/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  041451 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000828781A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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