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General NPI Number Information
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NPI Number | 1386767473
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Entity Type | Organization
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Legal Business Name | IMHOTEP MEDICAL SERVICES, INC.
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 10/06/2014
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Provider Practice Location Address
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Address Line | 5525 GREENWAY ST
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City | DETROIT
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State | MI
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Zip | 48204-2112
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Country | US
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Telephone | 313-935-0399
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Fax | 313-931-9113
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Provider Business Mailing Address
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Address Line | 5525 GREENWAY ST SUITE B - 2
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City | DETROIT
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State | MI
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Zip | 48204-2112
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Country | US
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Telephone | 313-701-1187
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Fax | 313-931-9113
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Authorized Official
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Title or Position | OWNER, PHYSICIAN
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Name | MS. CONNIE L MITCHELL
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Credential | M.D.
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Telephone | 313-701-1187
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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 | M4301056553
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License Number State | MI
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