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General NPI Number Information
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NPI Number | 1184711517
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MEDICAL CLINIC, P.C.
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 05/28/2015
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Provider Practice Location Address
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Address Line | 1235 INDIAN TRAIL ROAD SUITE 200
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City | NORCROSS
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State | GA
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Zip | 30093
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Country | US
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Telephone | 770-931-1333
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Fax | 770-931-3111
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Provider Business Mailing Address
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Address Line | PO BOX 1553
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City | DULUTH
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State | GA
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Zip | 30096
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Country | US
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Telephone | 770-931-1333
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Fax | 770-931-3111
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. SURESH H SHAH
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Credential | M.D.
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Telephone | 770-931-1333
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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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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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