Healthcare Provider Details

I. General information

NPI: 1427051663
Provider Name (Legal Business Name): CHARLES S LANE III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WERNER ST
HOT SPRINGS AR
71913-6406
US

IV. Provider business mailing address

PO BOX 6005
HOT SPRINGS AR
71902-6005
US

V. Phone/Fax

Practice location:
  • Phone: 501-802-0013
  • Fax: 501-623-1465
Mailing address:
  • Phone: 501-802-0013
  • Fax: 501-623-1465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC5421
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: