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General NPI Number Information
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NPI Number | 1174864615
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Entity Type | Organization
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Legal Business Name | CENTRA MEDICAL GROUP SOUTHSIDE, LLC
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Dates
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Enumeration Date | 03/08/2013
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Last Update Date | 03/08/2013
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Provider Practice Location Address
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Address Line | 800 OAK ST
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City | FARMVILLE
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State | VA
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Zip | 23901-1199
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Country | US
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Telephone | 434-315-2530
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Fax |
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Provider Business Mailing Address
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Address Line | 1204 FENWICK DR
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City | LYNCHBURG
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State | VA
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Zip | 24502-2112
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP COO
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Name | WILLIAM BASS
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Credential |
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Telephone | 434-315-2432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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