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General NPI Number Information
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NPI Number | 1720073216
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Entity Type | Organization
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Legal Business Name | PHYSICIAN PROVIDERS GROUP PA
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Dates
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Enumeration Date | 09/12/2005
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Last Update Date | 07/03/2023
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Provider Practice Location Address
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Address Line | 305 S LINE AVE
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City | INVERNESS
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State | FL
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Zip | 34452-4605
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Country | US
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Telephone | 352-344-4791
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Fax | 352-344-3822
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Provider Business Mailing Address
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Address Line | PO BOX 1925
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City | LADY LAKE
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State | FL
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Zip | 32158-1925
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Country | US
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Telephone | 523-553-4075
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Fax | 888-770-3208
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Authorized Official
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Title or Position | MD/OWNER
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Name | ROBERT ULSETH
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Credential | MD
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Telephone | 352-344-4791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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