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General NPI Number Information
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NPI Number | 1356117626
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Entity Type | Organization
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Legal Business Name | MED79
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Dates
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Enumeration Date | 11/28/2023
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Last Update Date | 11/28/2023
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Provider Practice Location Address
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Address Line | 2304 W 29TH AVE
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City | PINE BLUFF
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State | AR
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Zip | 71603-5005
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Country | US
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Telephone | 501-804-5628
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Fax |
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Provider Business Mailing Address
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Address Line | 3805 WINTERS PL
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City | PINE BLUFF
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State | AR
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Zip | 71603-6413
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Country | US
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Telephone | 501-804-5628
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CHRISTOPHER KEITH MCDANIEL
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Credential | MD
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Telephone | 501-804-5628
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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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