Healthcare Provider Details

I. General information

NPI: 1871597377
Provider Name (Legal Business Name): ROBERT D. LANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

1000 EAST PARIS AVE SE
GRAND RAPIDS MI
49546-3691
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-3158
  • Fax: 616-988-0071
Mailing address:
  • Phone: 616-459-3158
  • Fax: 616-988-0071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301061594
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301061594
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: