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General NPI Number Information
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NPI Number | 1780803932
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Entity Type | Organization
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Legal Business Name | NORTHRIDGE FAMILY PRACTICE LLC
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Dates
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Enumeration Date | 04/25/2007
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Last Update Date | 01/13/2009
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Provider Practice Location Address
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Address Line | 3190 NORTHRIDGE DRIVE
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City | HALE
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State | MI
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Zip | 48739-9276
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Country | US
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Telephone | 989-728-6000
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Fax | 989-728-6003
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Provider Business Mailing Address
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Address Line | PO BOX 279
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City | HALE
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State | MI
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Zip | 48739-0279
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Country | US
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Telephone | 198-972-8600
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Fax | 989-728-6003
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Authorized Official
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Title or Position | OWNER
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Name | DEBRA PROVOAST
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Credential | NP
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Telephone | 989-728-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301061417
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207RC0001X
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Taxonomy Name | Clinical Cardiac Electrophysiology Physician
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License Number | 5101011670
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License Number State | MI
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