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General NPI Number Information
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NPI Number | 1922081249
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Entity Type | Individual
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Provider Name | JACOB C. MARSHALL JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/21/2005
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Last Update Date | 07/12/2010
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Provider Practice Location Address
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Address Line | 103 N OAK ST
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City | O FALLON
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State | IL
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Zip | 62269-1165
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Country | US
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Telephone | 888-577-6337
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Fax |
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Provider Business Mailing Address
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Address Line | 2200 BOWLER RD
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City | COLLINSVILLE
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State | IL
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Zip | 62234-7012
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Country | US
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Telephone | 618-977-9607
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Fax | 618-624-9302
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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 | 036102192
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 036-102192
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License Number State | IL
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