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General NPI Number Information
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NPI Number | 1982906400
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Entity Type | Organization
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Legal Business Name | PUERTO MEDICAL GROUP PSC
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Dates
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Enumeration Date | 12/04/2010
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Last Update Date | 12/08/2011
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Provider Practice Location Address
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Address Line | 10806 WARD AVE
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City | LOUISVILLE
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State | KY
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Zip | 40223-2659
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Country | US
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Telephone | 502-899-1246
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Fax | 234-567-4229
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Provider Business Mailing Address
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Address Line | PO BOX 436809
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City | LOUISVILLE
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State | KY
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Zip | 40253-6809
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Country | US
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Telephone | 502-899-1246
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Fax | 234-567-4229
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Authorized Official
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Title or Position | PRESIDENT
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Name | ALFONSO PUERTO
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Credential | MD
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Telephone | 502-899-1246
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | LL339
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License Number State | KY
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