Provider Demographics
NPI:1699741082
Name:LANE, ROBERT C (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
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 819
Mailing Address - Street 2:
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519-0819
Mailing Address - Country:US
Mailing Address - Phone:870-297-2475
Mailing Address - Fax:870-297-4380
Practice Address - Street 1:35 GRASSE STREET
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519
Practice Address - Country:US
Practice Address - Phone:870-297-2475
Practice Address - Fax:870-297-4380
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4350207L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102785001Medicaid
AR02113OtherCIGNA
53039OtherBLUE CROSS BLUE SHIELD
13676000000OtherQUALCHOICE
080145231Medicare PIN
C68653Medicare UPIN
13676000000OtherQUALCHOICE