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General NPI Number Information
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NPI Number | 1063628675
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE MEDICAL & PHYSICAL THERAPY, LLC
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 10/29/2007
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Provider Practice Location Address
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Address Line | 1415 HIGHWAY 85 N SUITE 310-314
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4035
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Country | US
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Telephone | 866-476-8913
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Fax |
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Provider Business Mailing Address
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Address Line | 1415 HIGHWAY 85 N SUITE 310-314
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4035
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Country | US
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Telephone | 866-476-8913
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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 | DR. STEVEN LOBEL
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Credential |
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Telephone | 866-476-8913
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 054590
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License Number State | GA
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