MEDICARE: MARK A. LANG, M.D., LLC

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	35072067	OH

General Provider Information

NPI Number	:	1528301488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK A. LANG, M.D., LLC

Provider Business Mailing Address
First Line	:	PO BOX 470803
Second Line	:
City	:	BROADVIEW HEIGHTS
State	:	OH
Zip	:	44147-0803
Country	:	US
Telephone Number	:	440-545-2272
Fax Number	:	440-545-5645

Provider Business Practice Location Address
First Line	:	303 E ROYALTON RD
Second Line	:	SUITE 204
City	:	BROADVIEW HEIGHTS
State	:	OH
Zip	:	44147-2591
Country	:	US
Telephone Number	:	440-545-2272
Fax Number	:	440-545-5645

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. MARK ANDREW LANG
Credential	:	M.D.
Telephone Number	:	440-545-2272

Provider Enumeration Date	:	03/28/2013
Last Update Date	:	03/28/2013

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