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General NPI Number Information
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NPI Number | 1669523270
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Entity Type | Organization
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Legal Business Name | SPECIALIST IN GASTROENTEROLOGY
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 04/25/2008
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Provider Practice Location Address
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Address Line | 11525 OLDE CABIN RD
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City | CREVE COEUR
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State | MO
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Zip | 63141-7146
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Country | US
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Telephone | 314-997-0554
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Fax | 314-997-5086
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Provider Business Mailing Address
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Address Line | 11525 OLDE CABIN RD
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City | CREVE COEUR
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State | MO
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Zip | 63141-7146
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Country | US
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Telephone | 314-997-0554
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Fax | 314-997-5086
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | MRS. PAULA D WILLIS
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Credential |
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Telephone | 314-997-0554
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | R4F99
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License Number State | MO
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