Healthcare Provider Details

I. General information

NPI: 1114181815
Provider Name (Legal Business Name): SCOTT THOMAS LANGE RPA, RRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 GULL RD STE 200
KALAMAZOO MI
49048-1638
US

IV. Provider business mailing address

9745 S CLINTON TRL
EATON RAPIDS MI
48827-8582
US

V. Phone/Fax

Practice location:
  • Phone: 269-388-6350
  • Fax:
Mailing address:
  • Phone: 517-490-5690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C1101X
TaxonomyCardiovascular-Interventional Technology Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: