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General NPI Number Information
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NPI Number | 1346290103
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Entity Type | Organization
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Legal Business Name | MEMORIAL HEALTH SYSTEM, INC.
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Dates
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Enumeration Date | 05/11/2006
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Last Update Date | 03/09/2016
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Provider Practice Location Address
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Address Line | 809 N MICHIGAN ST
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City | SOUTH BEND
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State | IN
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Zip | 46601-1088
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Country | US
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Telephone | 574-647-7300
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Fax |
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Provider Business Mailing Address
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Address Line | 710 N NILES AVE
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City | SOUTH BEND
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State | IN
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Zip | 46617-1924
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Country | US
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Telephone | 574-647-1610
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Fax |
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Authorized Official
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Title or Position | VP-CFO
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Name | JEFFREY COSTELLO
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Credential |
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Telephone | 574-647-3549
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0006X
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Taxonomy Name | Developmental - Behavioral Pediatrics Physician
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License Number | 01060385A
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License Number State | IN
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