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General NPI Number Information
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NPI Number | 1053599043
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Entity Type | Organization
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Legal Business Name | MAC - MACON ROAD LLC
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Dates
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Enumeration Date | 02/01/2008
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Last Update Date | 10/07/2008
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Provider Practice Location Address
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Address Line | 3465 MACON RD STE D
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City | COLUMBUS
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State | GA
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Zip | 31907-2582
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Country | US
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Telephone | 706-243-3051
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 84052
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City | COLUMBUS
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State | GA
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Zip | 31908-4052
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Country | US
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Telephone | 706-243-0626
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | ROBERT O'NEIL SNODDY
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Credential | MD
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Telephone | 706-243-3051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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