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General NPI Number Information
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NPI Number | 1033190129
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Entity Type | Organization
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Legal Business Name | MAE PHYSICIANS SURGERY CENTER, LLC
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Dates
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Enumeration Date | 11/07/2005
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Last Update Date | 04/10/2014
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Provider Practice Location Address
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Address Line | 1190 N STATE ST STE 102
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City | JACKSON
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State | MS
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Zip | 39202-2413
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Country | US
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Telephone | 601-968-1790
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Fax | 601-292-4531
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Provider Business Mailing Address
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Address Line | PO BOX 12673
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City | JACKSON
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State | MS
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Zip | 39236-2673
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Country | US
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Telephone | 601-968-1790
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Fax | 601-292-4531
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. CARLA GLAZE
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Credential |
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Telephone | 601-968-1790
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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