{
"Npi": {
"NPI": "1245544543",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PHILLIP A. IMMESOETE MD, LTD",
"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": "5401 N KNOXVILLE AVE",
"SecondLineMailingAddress": "SUITE 406",
"MailingAddressCityName": "PEORIA",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "61614-5098",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "309-691-0030",
"MailingAddressFaxNumber": "309-691-9262",
"FirstLinePracticeLocationAddress": "5401 N KNOXVILLE AVE",
"SecondLinePracticeLocationAddress": "SUITE 406",
"PracticeLocationAddressCityName": "PEORIA",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "61614-5098",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "309-691-0030",
"PracticeLocationAddressFaxNumber": "309-691-9262",
"EnumerationDate": "07/29/2010",
"LastUpdateDate": "07/29/2010",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "IMMESOETE",
"AuthorizedOfficialFirstName": "PHILLIP",
"AuthorizedOfficialMiddleName": "ARTHUR",
"AuthorizedOfficialTitle": "PHYSICIAN",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "309-691-0030",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "313M00000X",
"TaxonomyName": "Nursing Facility/Intermediate Care Facility",
"LicenseNumber": "036042568",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}