{
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"NPI": "1225650633",
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "BIRCH TREE PHYSICAL THERAPY AND WELLNESS, LLC",
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"FirstName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "611 S PACA ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BALTIMORE",
"MailingAddressStateName": "MD",
"MailingAddressPostalCode": "21230-2411",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "443-801-1472",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2000 GIRARD AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "BALTIMORE",
"PracticeLocationAddressStateName": "MD",
"PracticeLocationAddressPostalCode": "21211-1595",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "443-977-4470",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/08/2020",
"LastUpdateDate": "05/08/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MCCOMISKEY",
"AuthorizedOfficialFirstName": "SEAN",
"AuthorizedOfficialMiddleName": "VINCENT",
"AuthorizedOfficialTitle": "OWNER, PHYSICAL THERAPIST",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PT, DPT",
"AuthorizedOfficialTelephoneNumber": "443-977-4470",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QP2000X",
"TaxonomyName": "Physical Therapy Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}