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General NPI Number Information
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NPI Number | 1518279595
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Entity Type | Individual
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Provider Name | JOEL MARK GRISHAM M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/08/2010
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Last Update Date | 07/08/2010
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Provider Practice Location Address
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Address Line | 10837 LAUREL ST 101
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-7643
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Country | US
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Telephone | 562-208-1600
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Fax | 909-481-3679
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Provider Business Mailing Address
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Address Line | 5209 WESTLEIGH AVE
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City | LAS VEGAS
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State | NV
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Zip | 89146-3326
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Country | US
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Telephone | 702-878-9665
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Fax | 702-878-9665
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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 | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | C39296
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License Number State | CA
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