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General NPI Number Information
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NPI Number | 1629773460
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Entity Type | Individual
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Provider Name | CARSON POWELL MD
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Gender | Male
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Dates
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Enumeration Date | 04/03/2023
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Last Update Date | 06/16/2023
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Provider Practice Location Address
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Address Line | 2160 S 1ST AVE # 60153
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City | MAYWOOD
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State | IL
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Zip | 60153-3328
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Country | US
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Telephone | 788-488-8584
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Fax |
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Provider Business Mailing Address
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Address Line | 729 E NORTHSHORE DR
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City | SYRACUSE
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State | IN
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Zip | 46567-2140
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Country | US
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Telephone |
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 125.082700
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License Number State | IL
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