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General NPI Number Information
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NPI Number | 1003081522
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Entity Type | Organization
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Legal Business Name | EVANSTON SURGICAL CENTER LLC
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Dates
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Enumeration Date | 04/25/2008
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Last Update Date | 10/20/2008
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Provider Practice Location Address
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Address Line | 196 ARROWHEAD DR SUITE 8
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City | EVANSTON
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State | WY
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Zip | 82930-8752
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Country | US
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Telephone | 307-789-1390
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Fax | 307-789-1391
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Provider Business Mailing Address
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Address Line | 196 ARROWHEAD DR SUITE 8
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City | EVANSTON
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State | WY
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Zip | 82930-8752
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Country | US
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Telephone | 435-613-9500
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Fax | 435-613-9414
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Authorized Official
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Title or Position | OWNER/MD
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Name | DR. MICHAEL J O'CONNOR
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Credential |
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Telephone | 307-789-1390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 5079A
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License Number State | WY
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