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General NPI Number Information
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NPI Number | 1730425851
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Entity Type | Organization
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Legal Business Name | FOUNTAIN HEALTHCARE LIMITED LIABILITY COMPANY
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Dates
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Enumeration Date | 12/18/2012
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Last Update Date | 12/18/2012
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Provider Practice Location Address
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Address Line | 1639 N 1590TH RD
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City | STREATOR
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State | IL
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Zip | 61364-9644
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Country | US
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Telephone | 815-793-6611
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Fax | 630-592-7500
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Provider Business Mailing Address
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Address Line | 1639 N 1590TH RD
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City | STREATOR
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State | IL
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Zip | 61364-9644
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Country | US
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Telephone | 815-793-6611
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Fax | 630-592-7500
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MARK ALAN WARGO
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Credential | M.D.
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Telephone | 815-793-6611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 036099987
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License Number State | IL
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