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Individual
Inactive
Individual
Inactive
Sole proprietor
Provider details
NPI number
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
36046971
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036046971
—
IL
01
—
784310
MEDICARE
IL
Enumeration date
—
Last updated
—
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