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General NPI Number Information
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NPI Number | 1871842328
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Entity Type | Individual
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Provider Name | ELLEN ANN SEVENICH M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/30/2012
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Last Update Date | 08/30/2012
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Provider Practice Location Address
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Address Line | 3850 PARK NICOLLET AVE
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City | ST. LOUIS PARK
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State | MN
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Zip | 55416
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Country | US
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Telephone | 651-993-3123
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Fax |
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Provider Business Mailing Address
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Address Line | 2335 STEWART AVE. 217
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City | ST. PAUL
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State | MN
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Zip | 55116
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Country | US
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Telephone | 651-698-4522
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 37235
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License Number State | MN
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