Provider Demographics
NPI:1427051663
Name:LANE, CHARLES S III (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
Last Name:LANE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6005
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71902-6005
Mailing Address - Country:US
Mailing Address - Phone:501-802-0013
Mailing Address - Fax:501-623-1465
Practice Address - Street 1:300 WERNER ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6406
Practice Address - Country:US
Practice Address - Phone:501-802-0013
Practice Address - Fax:501-623-1465
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC54212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR260001316OtherRAILROAD MEDICARE
ARB002OtherWPS TRICARE
AR102459001Medicaid
AR53036OtherBLUE CROSS BLUE SHIELD AR
AR102459001Medicaid
AR53036OtherBLUE CROSS BLUE SHIELD AR