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General NPI Number Information
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NPI Number | 1336378165
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Entity Type | Organization
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Legal Business Name | RIVERSIDE MEDICAL DIAGNOSTIC AND IMAGING, LLC
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Dates
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Enumeration Date | 07/14/2009
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Last Update Date | 09/28/2009
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Provider Practice Location Address
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Address Line | 2151 RIVERSIDE AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4416
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Country | US
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Telephone | 904-389-6707
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Fax | 904-389-6717
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Provider Business Mailing Address
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Address Line | 2151 RIVERSIDE AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4416
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Country | US
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Telephone | 904-389-6707
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Fax | 904-389-6717
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | MR. CORBY MARSHALL
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Credential |
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Telephone | 912-253-0375
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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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 | 261QR0206X
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Taxonomy Name | Mammography Clinic/Center
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License Number |
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License Number State |
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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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License Number State |
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