{
"Npi": {
"NPI": "1043307978",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "NEIL WANGSTROM MD PC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "304 DETROIT ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LA PORTE",
"MailingAddressStateName": "IN",
"MailingAddressPostalCode": "46350-2473",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "219-325-3770",
"MailingAddressFaxNumber": "219-325-8181",
"FirstLinePracticeLocationAddress": "304 DETROIT ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "LA PORTE",
"PracticeLocationAddressStateName": "IN",
"PracticeLocationAddressPostalCode": "46350-2473",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "219-325-3770",
"PracticeLocationAddressFaxNumber": "219-325-8181",
"EnumerationDate": "10/10/2006",
"LastUpdateDate": "09/29/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HENRICH",
"AuthorizedOfficialFirstName": "ROBIN",
"AuthorizedOfficialMiddleName": "M",
"AuthorizedOfficialTitle": "PRACTICE MANAGER",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "CMPC",
"AuthorizedOfficialTelephoneNumber": "219-325-3770",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "231H00000X",
"TaxonomyName": "Audiologist",
"LicenseNumber": "23002292A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "71001701A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "71001740A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207Y00000X",
"TaxonomyName": "Otolaryngology Physician",
"LicenseNumber": "01038858",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}