MEDICARE: JAMES R. LANE III PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	10140	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154476885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES R. LANE III PHD

Provider Business Mailing Address
First Line	:	116 LAWRENCE DR
Second Line	:	SUITE 4
City	:	COLUMBUS
State	:	MS
Zip	:	39702-5319
Country	:	US
Telephone Number	:	662-329-0114
Fax Number	:	662-329-0114

Provider Business Practice Location Address
First Line	:	116 LAWRENCE DR
Second Line	:	SUITE 4
City	:	COLUMBUS
State	:	MS
Zip	:	39702-5319
Country	:	US
Telephone Number	:	662-329-0114
Fax Number	:	662-329-0114

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/09/2007

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