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General NPI Number Information
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NPI Number | 1184976136
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Entity Type | Organization
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Legal Business Name | RACC MEDICAL ASSOCIATES LLC
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Dates
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Enumeration Date | 10/15/2012
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Last Update Date | 11/05/2024
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Provider Practice Location Address
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Address Line | 1721 MAGNAVOX WAY
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City | FORT WAYNE
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State | IN
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Zip | 46804-1537
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Country | US
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Telephone | 260-748-3650
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Fax | 260-748-3651
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Provider Business Mailing Address
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Address Line | 1721 MAGNAVOX WAY STE B
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City | FORT WAYNE
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State | IN
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Zip | 46804-1537
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Country | US
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Telephone | 260-748-3650
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Fax | 260-748-3651
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Authorized Official
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Title or Position | OWNER
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Name | DANIEL C ROTH
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Credential | DO
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Telephone | 260-748-3650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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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 | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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Taxonomy #3
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Taxonomy Code | 261QM1200X
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Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
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License Number |
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Taxonomy #4
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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