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General NPI Number Information
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NPI Number | 1447531876
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Entity Type | Organization
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Legal Business Name | ADOLPHUS MEDICAL GROUP
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Dates
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Enumeration Date | 08/30/2011
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Last Update Date | 08/30/2011
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Provider Practice Location Address
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Address Line | 406 E CAMP WISDOM RD SUITE A
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City | DALLAS
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State | TX
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Zip | 75241
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Country | US
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Telephone | 682-478-9117
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Fax | 817-887-2305
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Provider Business Mailing Address
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Address Line | 2515 MCKINNEY AVE SUITE 940
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City | DALLAS
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State | TX
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Zip | 75201-1908
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Country | US
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Telephone | 682-478-9117
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Fax | 817-887-2305
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Authorized Official
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Title or Position | DIRECTOR
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Name | GRACE STANLEY
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Credential | MD
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Telephone | 817-614-9180
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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 | N9413
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License Number State | TX
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