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General NPI Number Information
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NPI Number | 1104891472
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Entity Type | Individual
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Provider Name | KENNETH L BOSS MD
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Gender | Male
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Dates
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Enumeration Date | 02/21/2006
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 820 MAPLE ST
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City | CARROLLTON
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State | GA
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Zip | 30117-3626
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Country | US
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Telephone | 678-390-7915
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 728
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City | BREMEN
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State | GA
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Zip | 30110-0728
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Country | US
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Telephone | 770-537-1234
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 052425
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License Number State | GA
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