{
"Npi": {
"NPI": "1457563447",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PREMIER IMAGE COSMETIC & LASER SURGERY",
"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": "4553 N SHALLOWFORD ROAD",
"SecondLineMailingAddress": "20B",
"MailingAddressCityName": "ATLANTA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30338",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "770-457-6303",
"MailingAddressFaxNumber": "770-457-2823",
"FirstLinePracticeLocationAddress": "4553 N SHALLOWFORD ROAD",
"SecondLinePracticeLocationAddress": "20B",
"PracticeLocationAddressCityName": "ATLANTA",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30338",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "770-457-6303",
"PracticeLocationAddressFaxNumber": "770-457-2823",
"EnumerationDate": "05/04/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HAMES",
"AuthorizedOfficialFirstName": "JEANETTE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PRACTICE ADMINISTRATOR",
"AuthorizedOfficialNamePrefix": "MS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "770-457-6303",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "174400000X",
"TaxonomyName": "Specialist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}