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General NPI Number Information
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NPI Number | 1245055227
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Entity Type | Organization
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Legal Business Name | DOCTOR MIKE LLC
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Dates
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Enumeration Date | 11/15/2024
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Last Update Date | 11/15/2024
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Provider Practice Location Address
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Address Line | 305 COLLEGE ST W
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City | FAYETTEVILLE
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State | TN
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Zip | 37334-2911
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Country | US
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Telephone | 931-227-4984
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Fax | 931-227-4985
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Provider Business Mailing Address
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Address Line | 305 COLLEGE ST W
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City | FAYETTEVILLE
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State | TN
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Zip | 37334-2911
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Country | US
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Telephone | 931-227-4984
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Fax | 931-227-4985
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Authorized Official
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Title or Position | MD/OWNER
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Name | MICHAEL PETER LOIACONO
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Credential | MD
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Telephone | 931-227-6091
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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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