{
"Npi": {
"NPI": "1174702708",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "ST MARYS HOSPITAL DECATUR OF THE HOSPITAL SISTERS OF THE THIRD ORDER",
"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": "3051 HOLLIS DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SPRINGFIELD",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "62704-7450",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "217-464-2966",
"MailingAddressFaxNumber": "217-464-1039",
"FirstLinePracticeLocationAddress": "1900 E LAKE SHORE DR",
"SecondLinePracticeLocationAddress": "SUITE 200",
"PracticeLocationAddressCityName": "DECATUR",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "62521-3824",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "217-464-1030",
"PracticeLocationAddressFaxNumber": "217-464-1039",
"EnumerationDate": "10/31/2007",
"LastUpdateDate": "10/31/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "EVARD",
"AuthorizedOfficialFirstName": "MARK",
"AuthorizedOfficialMiddleName": "D",
"AuthorizedOfficialTitle": "VP OF REVENUE CYCLE",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "217-492-9651",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363A00000X",
"TaxonomyName": "Physician Assistant",
"LicenseNumber": "085-003034",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}