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General NPI Number Information
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NPI Number | 1083864219
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Entity Type | Organization
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Legal Business Name | RENOVO MEDICAL LLC
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Dates
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Enumeration Date | 09/24/2008
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Last Update Date | 03/05/2016
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Provider Practice Location Address
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Address Line | 816 N CAMPUS DR SUITE 500
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City | GARDEN CITY
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State | KS
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Zip | 67846-6329
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Country | US
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Telephone | 620-805-5162
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Fax | 620-805-5183
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Provider Business Mailing Address
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Address Line | 816 N CAMPUS DR SUITE 500
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City | GARDEN CITY
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State | KS
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Zip | 67846-6329
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Country | US
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Telephone | 620-805-5162
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Fax | 620-805-5183
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Authorized Official
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Title or Position | CEO/PHYSICIAN ASSISTANT
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Name | PROF. JOEL T ERSKIN
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Credential | SCD PA-C
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Telephone | 620-805-5162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202K00000X
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Taxonomy Name | Phlebology Physician
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License Number | 0416265
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 1500265
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License Number State | KS
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 45404
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License Number State | KS
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Taxonomy #4
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | KS0434389
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License Number State | KS
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