{
"Npi": {
"NPI": "1255043915",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "COWFISH INDUSTRIES LLC",
"ParentOrgTIN": null,
"OrgName": "MOOSALLY MEDICAL",
"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": "8905 SOUTH ST SE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WARREN",
"MailingAddressStateName": "OH",
"MailingAddressPostalCode": "44484-2357",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "330-402-3443",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2537 E MARKET ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WARREN",
"PracticeLocationAddressStateName": "OH",
"PracticeLocationAddressPostalCode": "44483-6257",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "330-460-5514",
"PracticeLocationAddressFaxNumber": "330-595-4366",
"EnumerationDate": "12/14/2022",
"LastUpdateDate": "12/14/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MOOSALLY",
"AuthorizedOfficialFirstName": "ROBERT",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER/PHYSICIAN",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "DO",
"AuthorizedOfficialTelephoneNumber": "330-460-5514",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QP2300X",
"TaxonomyName": "Primary Care Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}