MEDICARE: DR. EDWIN L DELANGE D.O. PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ED008382	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30-0010621	OTHER	MI	STATE LICENSE NUMBER
2	5440014	OTHER	MI	BCBS PIN #

General Provider Information

NPI Number	:	1073510723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWIN L DELANGE D.O. PC

Provider Business Mailing Address
First Line	:	1461 BALDWIN RD
Second Line	:
City	:	LAPEER
State	:	MI
Zip	:	48446-9776
Country	:	US
Telephone Number	:	810-667-2923
Fax Number	:

Provider Business Practice Location Address
First Line	:	3273 DAVISON RD
Second Line	:	STE 2
City	:	LAPEER
State	:	MI
Zip	:	48446-2902
Country	:	US
Telephone Number	:	810-667-8840
Fax Number	:	810-667-8846

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	01/12/2012

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