{
"Npi": {
"NPI": "1124115944",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "TONY C ROISUM MD PA",
"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": "3360 WASHINGTON PKWY",
"SecondLineMailingAddress": "SUITE 1",
"MailingAddressCityName": "IDAHO FALLS",
"MailingAddressStateName": "ID",
"MailingAddressPostalCode": "83404-8333",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "208-524-3416",
"MailingAddressFaxNumber": "208-524-3138",
"FirstLinePracticeLocationAddress": "3360 WASHINGTON PKWY",
"SecondLinePracticeLocationAddress": "SUITE 1",
"PracticeLocationAddressCityName": "IDAHO FALLS",
"PracticeLocationAddressStateName": "ID",
"PracticeLocationAddressPostalCode": "83404-8333",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "208-524-3416",
"PracticeLocationAddressFaxNumber": "208-524-3138",
"EnumerationDate": "10/05/2006",
"LastUpdateDate": "05/20/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": "07/24/2007",
"NPIReactivationDate": "12/09/2008",
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ROISUM",
"AuthorizedOfficialFirstName": "TONY",
"AuthorizedOfficialMiddleName": "C",
"AuthorizedOfficialTitle": "OWNER / PRESIDENT",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "208-524-3416",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207QS0010X",
"TaxonomyName": "Sports Medicine (Family Medicine) Physician",
"LicenseNumber": "M7389",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207Q00000X",
"TaxonomyName": "Family Medicine Physician",
"LicenseNumber": "M7389",
"LicenseNumberStateCode": "ID",
"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."
}
]
}
}
}