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General NPI Number Information
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NPI Number | 1750736088
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Entity Type | Individual
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Provider Name | MR. MARK WILSON
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Gender | Male
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Dates
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Enumeration Date | 04/23/2016
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Last Update Date | 04/23/2016
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Provider Practice Location Address
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Address Line | 5313 OGDEN ST
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City | PHILADELPHIA
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State | PA
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Zip | 19139-1438
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Country | US
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Telephone | 215-600-9477
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Fax | 215-921-8499
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Provider Business Mailing Address
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Address Line | 5313 OGDEN ST
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City | PHILADELPHIA
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State | PA
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Zip | 19139-1438
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Country | US
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Telephone | 215-600-9477
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Fax | 215-921-8499
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | A-6418104
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License Number State | PA
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