Basic Information
| Provider Information | |||||||||
| NPI: | 1003077090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANGENBERG | ||||||||
| FirstName: | LARS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16149 | ||||||||
| Address2: | |||||||||
| City: | RUMFORD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029160697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014539625 | ||||||||
| FaxNumber: | 4014357069 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 DUDLEY ST | ||||||||
| Address2: | SUITE 470 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029053236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015538318 | ||||||||
| FaxNumber: | 4018682307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | L-236269 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2086S0129X | MD15584 | RI | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.