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General NPI Number Information
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NPI Number | 1992921621
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Entity Type | Individual
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Provider Name | PRAVEENA SAMPATH M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1455 S LAPEER RD SUITE 134
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City | LAKE ORION
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State | MI
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Zip | 48360-1467
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Country | US
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Telephone | 248-683-3385
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Fax | 248-683-8441
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Provider Business Mailing Address
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Address Line | 2111 DORCHESTER DR N
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City | TROY
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State | MI
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Zip | 48084-3777
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Country | US
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Telephone | 248-614-3114
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Fax |
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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 | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 4301077694
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License Number State | MI
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