1770725467 NPI number — DR. BENJAMIN BJORN LANGE M.D.

Table of content: DR. BENJAMIN BJORN LANGE M.D. (NPI 1770725467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770725467 NPI number — DR. BENJAMIN BJORN LANGE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANGE
Provider First Name:
BENJAMIN
Provider Middle Name:
BJORN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770725467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 1/2 BEACON ST
Provider Second Line Business Mailing Address:
STE 199
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03301-4447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-228-1521
Provider Business Mailing Address Fax Number:
603-225-2510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLCHESTER AVE
Provider Second Line Business Practice Location Address:
FLETCHER ALLEN HEALTH CARE - DEPARTMENT OF RADIOLOGY
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401-1473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-556-0921
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  042.0012310 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)