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General NPI Number Information
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NPI Number | 1871690081
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Entity Type | Organization
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Legal Business Name | BACK & SPINE MEDICAL INSTITUTE
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 11/16/2007
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Provider Practice Location Address
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Address Line | 5300 N ILLINOIS ST
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City | FAIRVIEW HEIGHTS
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State | IL
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Zip | 62208-3500
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Country | US
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Telephone | 618-222-2222
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Fax |
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Provider Business Mailing Address
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Address Line | 1836 LACKLAND HILL PKWY
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City | SAINT LOUIS
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State | MO
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Zip | 63146-3572
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Country | US
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Telephone | 314-989-0300
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Fax |
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Authorized Official
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Title or Position | MD/OWNER
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Name | DR. RANDY JOHNSON
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Credential |
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Telephone | 314-781-8082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State | IL
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