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General NPI Number Information
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NPI Number | 1124282306
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Entity Type | Individual
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Provider Name | BASSEL JALLAD MBBS
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Gender | Male
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Dates
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Enumeration Date | 07/16/2008
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Last Update Date | 03/14/2017
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Provider Practice Location Address
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Address Line | 3655 VISTA AVE WEST PAVILION
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City | SAINT LOUIS
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State | MO
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Zip | 63110-2539
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Country | US
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Telephone | 314-268-7109
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Fax |
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Provider Business Mailing Address
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Address Line | 223 CLAYTON TRAILS DR
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City | ELLISVILLE
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State | MO
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Zip | 63011-2013
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Country | US
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Telephone | 708-890-6674
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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 | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | 2014031104
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License Number State | MO
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