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General NPI Number Information
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NPI Number | 1699425314
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Entity Type | Organization
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Legal Business Name | EVOLUTION MD, LLC
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Dates
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Enumeration Date | 03/25/2022
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Last Update Date | 04/11/2022
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Provider Practice Location Address
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Address Line | 522 N NEW BALLAS RD STE 317
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City | CREVE COEUR
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State | MO
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Zip | 63141-6840
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Country | US
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Telephone | 636-534-0200
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Fax | 636-534-0201
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Provider Business Mailing Address
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Address Line | PO BOX 37002
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City | SAINT LOUIS
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State | MO
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Zip | 63141-1502
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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 | OWNER
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Name | JOSE MARINO PARRA
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Credential | MD
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Telephone | 636-534-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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