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General NPI Number Information
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NPI Number | 1407114739
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Entity Type | Organization
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Legal Business Name | BOLA SOGADE, MD, LLC
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Dates
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Enumeration Date | 04/24/2012
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Last Update Date | 04/24/2012
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Provider Practice Location Address
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Address Line | 639 HEMLOCK ST
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City | MACON
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State | GA
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Zip | 31201-6886
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Country | US
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Telephone | 478-745-3014
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Fax |
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Provider Business Mailing Address
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Address Line | 639 HEMLOCK ST
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City | MACON
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State | GA
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Zip | 31201-6886
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Country | US
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Telephone | 478-745-3014
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | BOLA SOGADE
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Credential | MD
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Telephone | 478-745-3014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 6409
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License Number State | GA
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