Healthcare Provider Details

I. General information

NPI: 1467940510
Provider Name (Legal Business Name): WILLIAM KYLE LANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MARKET ST
BOARDMAN OH
44512-6725
US

IV. Provider business mailing address

1761 OAKMOUNT RD
SOUTH EUCLID OH
44121-4007
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-8757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.015195
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: