=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568490969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE S LANE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 656 STATE ST
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-941-4036
-----------------------------------------------------
Fax | 207-941-4062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 TREWORGY LN
-----------------------------------------------------
City | SURRY
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04684-3766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-941-4080
-----------------------------------------------------
Fax | 207-941-4077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 006910
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------