Provider Demographics
NPI:1073510723
Name:DELANGE, EDWIN L (DO PC)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:L
Last Name:DELANGE
Suffix:
Gender:M
Credentials:DO PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-9776
Mailing Address - Country:US
Mailing Address - Phone:810-667-2923
Mailing Address - Fax:
Practice Address - Street 1:3273 DAVISON RD
Practice Address - Street 2:STE 2
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2902
Practice Address - Country:US
Practice Address - Phone:810-667-8840
Practice Address - Fax:810-667-8846
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIED008382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30-0010621OtherSTATE LICENSE NUMBER
MI5440014OtherBCBS PIN #
MIMI5089Medicare PIN
MIE25799Medicare UPIN