Provider Demographics
NPI:1114003746
Name:MICHAEL W LANE MD PC
Entity type:Organization
Organization Name:MICHAEL W LANE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-641-6741
Mailing Address - Street 1:PO BOX 3556
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-3556
Mailing Address - Country:US
Mailing Address - Phone:804-641-6741
Mailing Address - Fax:804-861-0050
Practice Address - Street 1:95 PINEHILL BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9233
Practice Address - Country:US
Practice Address - Phone:804-641-6741
Practice Address - Fax:804-861-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicaid
VAPENDINGMedicaid