Provider Demographics
NPI:1154407427
Name:LANE, EDMUND (MD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:
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 636019
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9400 RHEA COUNTY HWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-7922
Practice Address - Country:US
Practice Address - Phone:423-775-1121
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN011582207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00281706OtherRAILROAD MEDICARE
TN3332203Medicaid
TN3011754OtherBCBS OF TENNESSEE
TNB04155Medicare UPIN
TN3332203Medicare PIN