{
"Npi": {
"NPI": "1124823059",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SPORTS MEDICINE ASSOCIATES OF SAN ANTONIO, PA",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 268996",
"SecondLineMailingAddress": "DEPT 1131",
"MailingAddressCityName": "OKLAHOMA CITY",
"MailingAddressStateName": "OK",
"MailingAddressPostalCode": "73126",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "210-699-8326",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "112 HERFF RD STE 300",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "BOERNE",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "78006-2750",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "210-699-8326",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "02/14/2025",
"LastUpdateDate": "02/14/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BIRKELO",
"AuthorizedOfficialFirstName": "JULIE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CREDENTIALING SPECIALIST",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "210-756-5240",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207X00000X",
"TaxonomyName": "Orthopaedic Surgery Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "332B00000X",
"TaxonomyName": "Durable Medical Equipment & Medical Supplies",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207XX0005X",
"TaxonomyName": "Sports Medicine (Orthopaedic Surgery) Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
]
}
}
}