Basic Information
| Provider Information | |||||||||
| NPI: | 1407078884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 SPRING HILL AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366041410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514352663 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1720 SPRING HILL AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366041410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514352663 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 240326 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 28325 | AL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 240326 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 25MA07510700 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 25MA07510700 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009910928 | 05 | AL | MEDICAID |