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General NPI Number Information
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NPI Number | 1467970319
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Entity Type | Individual
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Provider Name | MARCUS ROACH
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Gender | Male
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Dates
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Enumeration Date | 08/30/2017
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Last Update Date | 08/30/2017
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Provider Practice Location Address
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Address Line | 912 OAKCREST DR. APT D
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City | CHARLESTON
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State | IL
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Zip | 61920
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Country | US
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Telephone | 217-208-1415
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Fax |
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Provider Business Mailing Address
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Address Line | 912 OAKCREST DR APT D
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City | CHARLESTON
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State | IL
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Zip | 61920-1780
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Country | US
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Telephone | 785-338-1964
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160.007167
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License Number State | IL
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