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General NPI Number Information
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NPI Number | 1821520107
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Entity Type | Individual
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Provider Name | MAKSIM BOGUSLAVSKIY DO
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Gender | Male
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 09/09/2024
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Provider Practice Location Address
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Address Line | 500 PLAZA CT
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City | EAST STROUDSBURG
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State | PA
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Zip | 18301-8262
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Country | US
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Telephone | 570-426-2301
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 MACK BLVD FL 4
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City | ALLENTOWN
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State | PA
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Zip | 18103-5622
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Country | US
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Telephone |
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Fax |
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 73584
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 2086S0102X
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Taxonomy Name | Surgical Critical Care Physician
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License Number | OS023953
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License Number State | PA
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