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General NPI Number Information
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NPI Number | 1609376409
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Entity Type | Organization
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Legal Business Name | KOKOMO AMBULATORY SURGERY CENTER
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Dates
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Enumeration Date | 02/19/2018
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Last Update Date | 02/19/2018
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Provider Practice Location Address
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Address Line | 107 S WASHINGTON ST STE A
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City | KOKOMO
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State | IN
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Zip | 46901-4601
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Country | US
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Telephone | 765-450-6735
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Fax | 765-838-3200
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Provider Business Mailing Address
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Address Line | PO BOX 5748
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City | LAFAYETTE
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State | IN
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Zip | 47903-5748
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Country | US
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Telephone | 765-714-4344
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHAZIA M SIDDIQUI
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Credential | MD
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Telephone | 765-450-6735
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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