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General NPI Number Information
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NPI Number | 1225427826
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Entity Type | Individual
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Provider Name | JOHN GILLAM DPT
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Gender | Male
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Dates
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Enumeration Date | 01/20/2015
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Last Update Date | 01/20/2015
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Provider Practice Location Address
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Address Line | 2200 WALLACE BLVD SUITE E
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City | CINNAMINSON
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State | NJ
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Zip | 08077-2578
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Country | US
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Telephone | 856-829-0015
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Fax | 856-829-0043
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Provider Business Mailing Address
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Address Line | 4175 VETERANS MEMORIAL HWY STE 202
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City | RONKONKOMA
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State | NY
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Zip | 11779-7639
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Country | US
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Telephone | 631-580-5200
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Fax | 631-580-5222
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 40QA01495300
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License Number State | NJ
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