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General NPI Number Information
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NPI Number | 1891028650
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Entity Type | Organization
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Legal Business Name | HEALTHSOURCE MEDICAL SERVICES PLLC
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Dates
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Enumeration Date | 09/11/2009
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Last Update Date | 08/11/2014
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Provider Practice Location Address
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Address Line | 3001 EXPRESS DR N STE 200C
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City | ISLANDIA
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State | NY
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Zip | 11749-5301
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Country | US
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Telephone | 631-435-0110
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 206
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City | EAST SETAUKET
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State | NY
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Zip | 11733-0206
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Country | US
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Telephone | 631-435-0110
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Fax |
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Authorized Official
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Title or Position | MD
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Name | DR. JOHN FOLAN
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Credential | M.D
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Telephone | 631-435-0110
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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 | 167755
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License Number State | NY
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