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General NPI Number Information
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NPI Number | 1174813737
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Entity Type | Organization
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Legal Business Name | PEDIATRIC CARDIOLOGY SERVICES, LLC
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Dates
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Enumeration Date | 04/15/2011
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Last Update Date | 09/12/2012
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Provider Practice Location Address
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Address Line | 500 MEDICAL CENTER BLVD SUITE 390
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-8708
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Country | US
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Telephone | 770-995-6684
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Fax | 770-995-7631
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Provider Business Mailing Address
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Address Line | 500 MEDICAL CENTER BLVD SUITE 390
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-8708
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Country | US
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Telephone | 770-995-6684
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Fax | 770-995-7631
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Authorized Official
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Title or Position | CEO
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Name | NEILL VIDELEFSKY
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Credential | MD
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Telephone | 770-995-6684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number |
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License Number State | GA
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