{
"Npi": {
"NPI": "1265634711",
"EntityType": "Organization",
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"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "THERESA A. TRAVIS,M.D.,PC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherOrgNameTypeCode": null,
"OtherLastName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2516 Q ST",
"SecondLineMailingAddress": "SUITE B",
"MailingAddressCityName": "BEDFORD",
"MailingAddressStateName": "IN",
"MailingAddressPostalCode": "47421-4928",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "812-275-3328",
"MailingAddressFaxNumber": "812-279-5977",
"FirstLinePracticeLocationAddress": "2516 Q ST",
"SecondLinePracticeLocationAddress": "SUITE B",
"PracticeLocationAddressCityName": "BEDFORD",
"PracticeLocationAddressStateName": "IN",
"PracticeLocationAddressPostalCode": "47421-4928",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "812-275-3328",
"PracticeLocationAddressFaxNumber": "812-279-5977",
"EnumerationDate": "06/05/2007",
"LastUpdateDate": "04/08/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TRAVIS",
"AuthorizedOfficialFirstName": "THERESA",
"AuthorizedOfficialMiddleName": "ANN",
"AuthorizedOfficialTitle": "M.D.",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "812-275-3328",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207RN0300X",
"TaxonomyName": "Nephrology Physician",
"LicenseNumber": "01036752A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}