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General NPI Number Information
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NPI Number | 1912197294
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Entity Type | Organization
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Legal Business Name | MODESTO NEONATAL MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 08/01/2007
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Last Update Date | 08/01/2007
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Provider Practice Location Address
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Address Line | 1441 FLORIDA AVE
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City | MODESTO
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State | CA
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Zip | 95350-4405
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Country | US
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Telephone | 209-571-8330
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 577558
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City | MODESTO
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State | CA
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Zip | 95357-7558
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Country | US
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Telephone | 209-571-8330
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Fax | 209-491-7184
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Authorized Official
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Title or Position | BILLING AGENT
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Name | MRS. GINA WALLACE
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Credential |
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Telephone | 209-571-8330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080N0001X
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Taxonomy Name | Neonatal-Perinatal Medicine Physician
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License Number | 39491
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License Number State | CA
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