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General NPI Number Information
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NPI Number | 1285981852
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Entity Type | Organization
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Legal Business Name | AUSTIN MED GROUP INC
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Dates
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Enumeration Date | 08/13/2012
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Last Update Date | 09/18/2012
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Provider Practice Location Address
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Address Line | 515 S 700 E
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City | SALT LAKE CITY
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State | UT
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Zip | 84102-2801
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Country | US
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Telephone | 801-343-1220
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Fax |
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Provider Business Mailing Address
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Address Line | 515 S 700 E
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City | SALT LAKE CITY
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State | UT
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Zip | 84102-2801
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Country | US
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Telephone | 801-343-1220
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ADAM BOLAFT
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Credential |
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Telephone | 385-414-4720
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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 | 4859745-1265
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License Number State | UT
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