Provider Demographics
NPI:1164495669
Name:LANGE, MARLIS (MD)
Entity Type:Individual
Prefix:
First Name:MARLIS
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1998 STAR SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-8784
Mailing Address - Country:US
Mailing Address - Phone:269-948-3922
Mailing Address - Fax:
Practice Address - Street 1:1998 STAR SCHOOL RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-8784
Practice Address - Country:US
Practice Address - Phone:269-948-3922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105447207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH85261Medicare UPIN