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General NPI Number Information
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NPI Number | 1760537013
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Entity Type | Organization
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Legal Business Name | WEST SIDE MEDICAL CENTER, LLC
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 12/03/2013
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Provider Practice Location Address
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Address Line | 606 W MAIN ST
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City | NORWICH
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State | CT
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Zip | 06360-6007
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Country | US
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Telephone | 860-889-1400
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Fax | 860-889-3163
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Provider Business Mailing Address
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Address Line | 606 W MAIN ST
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City | NORWICH
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State | CT
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Zip | 06360-6007
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Country | US
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Telephone | 860-889-1400
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Fax | 860-889-3163
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Authorized Official
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Title or Position | OWNER
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Name | DR. WILLIAM H HERNANDEZ III
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Credential | M.D.
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Telephone | 860-889-1400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 005383
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 207Q00000X
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License Number State | CT
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