{
"Npi": {
"NPI": "1336444397",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PAIN MANAGEMENT & ORTHOPEDIC CENTER PC",
"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": "733 VOLVO PKWY STE 200",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CHESAPEAKE",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "23320-1609",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "757-962-2121",
"MailingAddressFaxNumber": "757-962-1911",
"FirstLinePracticeLocationAddress": "733 VOLVO PKWY STE 200",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHESAPEAKE",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "23320-1609",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "757-962-2121",
"PracticeLocationAddressFaxNumber": "757-962-1911",
"EnumerationDate": "01/21/2011",
"LastUpdateDate": "12/08/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PENNINGTON",
"AuthorizedOfficialFirstName": "TRACEY",
"AuthorizedOfficialMiddleName": "O",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "757-962-2121",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "174400000X",
"TaxonomyName": "Specialist",
"LicenseNumber": "0101034150",
"LicenseNumberStateCode": "VA",
"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."
}
}
}
}