{
"Npi": {
"NPI": "1154940401",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "SORRENTINO",
"FirstName": "SAM",
"MiddleName": "SCOTT",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "MD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1215 SW G ST.",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GRANTS PASS",
"MailingAddressStateName": "OR",
"MailingAddressPostalCode": "97526-2544",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "541-476-2373",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "200 BEATTY",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MEDFORD",
"PracticeLocationAddressStateName": "OR",
"PracticeLocationAddressPostalCode": "97501-5811",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "541-476-2373",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/15/2020",
"LastUpdateDate": "10/09/2024",
"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": "2084P0800X",
"TaxonomyName": "Psychiatry Physician",
"LicenseNumber": "MD219688",
"LicenseNumberStateCode": "OR",
"PrimaryTaxonomySwitch": "Y"
},
{
"TaxonomyCode": "2084P0800X",
"TaxonomyName": "Psychiatry Physician",
"LicenseNumber": "328669",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "N"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}