{
"Npi": {
"NPI": "1093737397",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "GANNON",
"FirstName": "MARK",
"MiddleName": "ROBERT",
"NamePrefix": "MR.",
"NameSuffix": null,
"Credential": "PT",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "600 OAKMONT LN STE 600C",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WESTMONT",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "60559-5548",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "630-575-1980",
"MailingAddressFaxNumber": "630-928-5080",
"FirstLinePracticeLocationAddress": "2011 YORK RD STE 1500",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "OAK BROOK",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "60523",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "877-632-6637",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/24/2006",
"LastUpdateDate": "06/07/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "225100000X",
"TaxonomyName": "Physical Therapist",
"LicenseNumber": "070024237",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
},
{
"TaxonomyCode": "225100000X",
"TaxonomyName": "Physical Therapist",
"LicenseNumber": "6877",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "N"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}