{
"Npi": {
"NPI": "1366786717",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "BELLOMO",
"FirstName": "WILLIAM",
"MiddleName": "GEORGE",
"NamePrefix": "MR.",
"NameSuffix": "II",
"Credential": "PTA",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "BELLOMO",
"OtherFirstName": "GEORGE",
"OtherMiddleName": null,
"OtherNamePrefix": "MR.",
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "2",
"FirstLineMailingAddress": "39343 AUGUSTA AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "STERLING HEIGHTS",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48313-5505",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "586-419-4362",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "39343 AUGUSTA AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "STERLING HEIGHTS",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "48313-5505",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "586-419-4362",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/23/2012",
"LastUpdateDate": "08/22/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "225200000X",
"TaxonomyName": "Physical Therapy Assistant",
"LicenseNumber": "5502003698",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "225700000X",
"TaxonomyName": "Massage Therapist",
"LicenseNumber": "7501003114",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "225700000X",
"TaxonomyName": "Massage Therapist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}