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General NPI Number Information
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NPI Number | 1104979582
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Entity Type | Organization
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Legal Business Name | PROVIDENCE FAMILY PRACTICE MEDICAL GROUP
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1213 COFFEE RD SUITE B
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City | MODESTO
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State | CA
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Zip | 95355-4229
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Country | US
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Telephone | 209-491-2500
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Fax | 209-491-2545
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Provider Business Mailing Address
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Address Line | 1213 COFFEE RD SUITE B
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City | MODESTO
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State | CA
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Zip | 95355-4229
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Country | US
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Telephone | 209-491-2500
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Fax | 209-491-2545
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | MRS. KATHIE LEE CRONIN
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Credential | M.D.
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Telephone | 209-491-2500
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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 |
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License Number State |
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