Healthcare Provider Details

I. General information

NPI: 1154639508
Provider Name (Legal Business Name): KATHRYN LEE SEROWKA LANE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN LEE SEROWKA LANE MD

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-1248
  • Fax: 217-366-6100
Mailing address:
  • Phone: 217-366-1248
  • Fax: 217-366-6100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036154202
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036154202
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: