Healthcare Provider Details

I. General information

NPI: 1043328495
Provider Name (Legal Business Name): LANCE RANDELL SEAGREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 GREENBUSH ST
LAFAYETTE IN
47904-2477
US

IV. Provider business mailing address

PO BOX 5545
LAFAYETTE IN
47903-5545
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax:
Mailing address:
  • Phone: 765-448-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number01029553A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: