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General NPI Number Information
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NPI Number | 1689031973
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Entity Type | Organization
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Legal Business Name | ODYSSEY EMERGENCY PHYSICIANS, LLC
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Dates
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Enumeration Date | 01/19/2016
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Last Update Date | 01/19/2016
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Provider Practice Location Address
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Address Line | 1 BAY AVE
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City | MONTCLAIR
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State | NJ
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Zip | 07042-4837
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Country | US
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Telephone | 469-401-2386
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 80043
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City | PHILADELPHIA
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State | PA
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Zip | 19101-1043
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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 | OFFICER
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Name | RUSSELL HARRIS
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Credential | M.D.
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Telephone | 469-401-2386
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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