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General NPI Number Information
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NPI Number | 1912107079
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Entity Type | Organization
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Legal Business Name | SOUTH DEKALB PEDIATRICS
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Dates
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Enumeration Date | 07/18/2007
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Last Update Date | 07/18/2007
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Provider Practice Location Address
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Address Line | 2395 WALL ST SE SUITE 700
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City | CONYERS
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State | GA
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Zip | 30013-6703
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Country | US
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Telephone | 404-243-9630
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Fax |
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Provider Business Mailing Address
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Address Line | 2395 WALL ST SE SUITE 700
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City | CONYERS
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State | GA
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Zip | 30013-6703
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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 | PRACTICE ADMINISTRATOR
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Name | JORON R. MURRY
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Credential | CMPE, CPC
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Telephone | 404-243-9630
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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