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General NPI Number Information
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NPI Number | 1821267832
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Entity Type | Organization
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Legal Business Name | EASTLAKE MEDICAL CENTER
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Dates
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Enumeration Date | 02/23/2008
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Last Update Date | 02/23/2008
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Provider Practice Location Address
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Address Line | 646 CHENE ST
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City | DETROIT
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State | MI
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Zip | 48207-3979
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Country | US
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Telephone | 248-747-3425
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Fax |
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Provider Business Mailing Address
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Address Line | 17520 W 12 MILE RD STE 116
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City | SOUTHFIELD
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State | MI
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Zip | 48076-1907
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Country | US
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Telephone | 248-443-6711
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Fax |
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Authorized Official
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Title or Position | PRESIDENT CEO
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Name | MRS. BIANCA FELICIA DOOLEY
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Credential |
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Telephone | 248-747-3425
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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