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General NPI Number Information
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NPI Number | 1437638574
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Entity Type | Organization
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Legal Business Name | IMAGINEMD
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Dates
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Enumeration Date | 08/09/2018
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Last Update Date | 08/09/2018
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Provider Practice Location Address
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Address Line | 10 S RIVERSIDE PLZ STE 2225
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City | CHICAGO
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State | IL
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Zip | 60606-3707
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Country | US
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Telephone | 312-374-5860
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 652
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City | CLEMSON
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State | SC
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Zip | 29633-0652
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Country | US
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Telephone | 773-364-0478
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. ALEX LICKERMAN
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Credential | MD
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Telephone | 312-374-5860
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 039.090525
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License Number State | IL
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