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General NPI Number Information
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NPI Number | 1265638969
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Entity Type | Individual
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Provider Name | GLENN ALLEN CHAMULAK M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/21/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1101 W UNIVERSITY DR DEPARTMENT OF PATHOLOGY
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City | ROCHESTER
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State | MI
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Zip | 48307-1863
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Country | US
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Telephone | 248-652-5264
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Fax | 248-652-5065
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Provider Business Mailing Address
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Address Line | 4099 AUTUMN VIEW CT
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City | FENTON
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State | MI
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Zip | 48430-9128
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Country | US
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Telephone | 810-750-6630
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Fax |
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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 | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 4301054047
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License Number State | MI
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