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General NPI Number Information
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NPI Number | 1699783886
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Entity Type | Organization
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Legal Business Name | JAMES R DEBORD
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Dates
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Enumeration Date | 08/03/2006
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Last Update Date | 06/01/2011
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Provider Practice Location Address
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Address Line | 5409 N KNOXVILLE AVE
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City | PEORIA
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State | IL
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Zip | 61614-5016
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Country | US
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Telephone | 877-852-4669
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10140
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City | PEORIA
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State | IL
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Zip | 61612-0140
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Country | US
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Telephone | 877-852-4669
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAMES DEBORD
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Credential | M.D.
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Telephone | 877-852-4669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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