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General NPI Number Information
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NPI Number | 1447454061
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Entity Type | Organization
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Legal Business Name | DIVERSIFY MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 06/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3318 DEL MAR AVE SUITE 205
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City | ROSEMEAD
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State | CA
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Zip | 91770-2373
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Country | US
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Telephone | 626-571-5577
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Fax | 626-571-7405
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Provider Business Mailing Address
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Address Line | 3318 DEL MAR AVE SUITE 205
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City | ROSEMEAD
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State | CA
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Zip | 91770-2373
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Country | US
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Telephone | 626-571-5577
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Fax | 626-571-7405
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MING-CHANG HSU
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Credential | M.D.
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Telephone | 626-571-5577
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | A34714
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License Number State | CA
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