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General NPI Number Information
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NPI Number | 1396113692
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Entity Type | Organization
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Legal Business Name | SHADOW PODIATRY
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Dates
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Enumeration Date | 09/03/2015
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Last Update Date | 09/03/2015
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Provider Practice Location Address
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Address Line | 26 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10004-1703
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Country | US
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Telephone | 646-551-6663
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Fax |
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Provider Business Mailing Address
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Address Line | 14431 70TH RD
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City | FLUSHING
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State | NY
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Zip | 11367-1717
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DOCTOR OF PODIATRIC MEDICINE
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Name | DR. DANIEL BASALELY
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Credential | DPM
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Telephone | 646-551-6663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 006679
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License Number State | NY
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