{
"Npi": {
"NPI": "1245325356",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "VA MEDICAL CENTER, PHILADELPHIA 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": "715 N. ITHAN AVENUE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ROSEMONT",
"MailingAddressStateName": "PA",
"MailingAddressPostalCode": "19010-1729",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "215-823-5182",
"MailingAddressFaxNumber": "215-823-4271",
"FirstLinePracticeLocationAddress": "3900 WOODLAND AVENUE",
"SecondLinePracticeLocationAddress": "PATHOLOGY & LAB. MED. (113) - VAMC CLIN. ADD. BLDG.",
"PracticeLocationAddressCityName": "PHILADELPHIA",
"PracticeLocationAddressStateName": "PA",
"PracticeLocationAddressPostalCode": "19104-4551",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "215-823-5182",
"PracticeLocationAddressFaxNumber": "215-823-4271",
"EnumerationDate": "10/04/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SULLIVAN",
"AuthorizedOfficialFirstName": "MICHAEL",
"AuthorizedOfficialMiddleName": "J",
"AuthorizedOfficialTitle": "DIRECTOR",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "215-823-5857",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "291U00000X",
"TaxonomyName": "Clinical Medical Laboratory",
"LicenseNumber": "MD-036835L",
"LicenseNumberStateCode": "PA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}