{
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"NPI": "1235494550",
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"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "GORDON & MANGAN TRAVELERS CLINIC, LLC",
"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": "21825 CHAGRIN BLVD.",
"SecondLineMailingAddress": "SUITE 345",
"MailingAddressCityName": "BEACHWOOD",
"MailingAddressStateName": "OH",
"MailingAddressPostalCode": "44122-5352",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "216-295-9400",
"MailingAddressFaxNumber": "216-283-8120",
"FirstLinePracticeLocationAddress": "21825 CHAGRIN BLVD.",
"SecondLinePracticeLocationAddress": "SUITE 345",
"PracticeLocationAddressCityName": "BEACHWOOD",
"PracticeLocationAddressStateName": "OH",
"PracticeLocationAddressPostalCode": "44122-5352",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "216-295-9400",
"PracticeLocationAddressFaxNumber": "216-283-8120",
"EnumerationDate": "07/12/2012",
"LastUpdateDate": "07/12/2012",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GORDON",
"AuthorizedOfficialFirstName": "EILEEN",
"AuthorizedOfficialMiddleName": "KILBANE",
"AuthorizedOfficialTitle": "CO-OWNER, EXECUTIVE DIRECTOR & CLIN",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "R.N.",
"AuthorizedOfficialTelephoneNumber": "216-295-9400",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "163W00000X",
"TaxonomyName": "Registered Nurse",
"LicenseNumber": "RN140601",
"LicenseNumberStateCode": "OH",
"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."
}
}
}
}