MEDICARE: DR. CHADRICK EUGENE LANE MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2084P0800X	Psychiatry Physician	S9731	TX

General Provider Information

NPI Number	:	1356761829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHADRICK EUGENE LANE MD

Provider Business Mailing Address
First Line	:	PO BOX 845347
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-5347
Country	:	US
Telephone Number	:	214-645-0624
Fax Number	:	214-645-0078

Provider Business Practice Location Address
First Line	:	6363 FOREST PARK RD 7TH FL STE 749
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-6624
Country	:	US
Telephone Number	:	214-645-8500
Fax Number	:	214-645-3775

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

Provider Enumeration Date	:	04/23/2014
Last Update Date	:	07/30/2021

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