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General NPI Number Information
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NPI Number | 1548479801
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Entity Type | Organization
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Legal Business Name | MOSAIC PRIME
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 11/17/2015
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Provider Practice Location Address
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Address Line | 20 DUDLEY ST SUITE 250
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City | MEMPHIS
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State | TN
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Zip | 38103-4904
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Country | US
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Telephone | 901-866-1655
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Fax | 866-359-8798
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Provider Business Mailing Address
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Address Line | 1318 MARSH CREEK LN
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City | COLLIERVILLE
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State | TN
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Zip | 38017-3940
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Country | US
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Telephone | 901-568-6009
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Fax | 866-359-8798
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Authorized Official
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Title or Position | CHIEF MEDICAL OFFICER
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Name | DR. JULIA DAHL
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Credential | M.D.
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Telephone | 901-568-6009
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 44D1053242
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License Number State | TN
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