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General NPI Number Information
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NPI Number | 1619288339
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Entity Type | Organization
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Legal Business Name | KIDANU BIRHANU MD SC
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Dates
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Enumeration Date | 06/28/2010
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Last Update Date | 06/28/2010
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Provider Practice Location Address
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Address Line | 24 JOLIET ST SUITE 302
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City | DYER
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State | IN
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Zip | 46311-1705
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Country | US
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Telephone | 219-852-2518
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Fax | 219-864-2156
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Provider Business Mailing Address
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Address Line | PO BOX 394
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City | DYER
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State | IN
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Zip | 46311-0394
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Country | US
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Telephone | 708-334-2352
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KIDANU BIRHANU
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Credential | MD
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Telephone | 708-334-2352
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 01066132A
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License Number State | IN
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